Financial Supplement for Business Insurance QuestionnairePlease answer all questions applicable to the client's medical history. Questions? Call Jim or Teresa at 877.564.1707. Producer Name* Phone* Email* Date MM slash DD slash YYYY Client Name Date of Birth MM slash DD slash YYYY Gender Male Female Owner: Beneficiary: AssetsCash and cash equivalents:Accounts Receivable:Inventories:Prepaid expense:Investments held for trading:Property, plant and equipment:Goodwill:Other intangible fixed assets:Deferred tax assets:TOTAL ASSETS:Net income for last tax fiscal year:Net income after tax current fiscal year:LiabilitiesAccounts payable:Current income tax liabilities:Bank loans:Other tax liabilities:Issued debt securities:Deferred tax liabilities:Minority interest and equity:Other liabilities:TOTAL LIABILITIES:NET WORTH:Retained earnings/stockholder equity:Fair market value of business: Type of business: C Corp S Corp Partnership Sole Proprietorship LLC LLP Number of employees: Year established: Description of business (mfg., retail, etc.) Purpose of insurance: Key person Buy/Sell Stock redemption Loan Deferred Comp Other If other, please describe: If Buy/Sell, provide names of all partners, percent of business owned, and amount of buy/sell insurance inforce and applied for: If Key Person, are all other key persons covered by or applying for comparable amounts of insurance? Yes No If no, please explain: If Loan, provide loan amount: Purpose of loan? Is firm involved in any judgements, lawsuits, or pending court proceedings? Yes No If yes, please explain: For Insurance Professional Use Only — not intended for use in solicitation of sales to the public. Products and programs offered through Tellus are not approved for use in all states. 07.06.17. Copyright © 2017 Tellus Brokerage Connections Δ