Financial Supplement for Personal 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: Purpose of Insurance AssetsCash (checking, savings, CDs):Accounts, loans, and notes receivable:U.S. Government and marketable securities:Real estate (market value):Personal Property (auto, furniture, etc.):Other assets (describe below):TOTAL ASSETS:LiabilitiesAccounts and notes payable:Real estate mortgages or liens:Other liabilities (describe below):TOTAL LIABILITIES:NET WORTH:Description of other assets: Description of other liabilities: Last completed tax year: Prior tax year: Annual Salary:Last Completed Tax YearPrior Tax Year Bonus and commissions:Last Completed Tax YearPrior Tax Year Dividends and interest:Last Completed Tax YearPrior Tax Year Pension/annuity:Last Completed Tax YearPrior Tax Year Real estate income:Last Completed Tax YearPrior Tax Year Other income (describe below):Last Completed Tax YearPrior Tax Year Description of other income including source: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