Moseleymcgill – Financial Supplement for Personal Insurance

Financial Supplement for Personal Insurance Questionnaire
Please 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
Assets
Cash (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:
Liabilities
Accounts 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 Year	Prior Tax Year

Bonus and commissions:

Last Completed Tax Year	Prior Tax Year

Dividends and interest:

Last Completed Tax Year	Prior Tax Year

Pension/annuity:

Last Completed Tax Year	Prior Tax Year

Real estate income:

Last Completed Tax Year	Prior Tax Year

Other income (describe below):

Last Completed Tax Year	Prior Tax Year

Description of other income including source:
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Financial Supplement for Personal Insurance