Intake Form

How will you be using this form?(Required)

Insurance

Investments

Who is your One Wealth Advisor?(Required)

Insurance Choices(Required)

Life

Disability

Long Term Care

Supplement for Business Policy

Joint Long Term Care

Investment Account Type(Required)

Add In(Required)

Beneficiaries

Trustees

If client will be transferring existing investment accounts, have you asked for account statement(s)?(Required)

Yes

N/A, funding with cash

Section I - General Information (Applicant 1)

Legal Name(Required)

First Middle Last

Mobile Phone(Required)

Email(Required)

DOB(Required)

Check if Not a US Citizen

Not a US Citizen

Gender(Required)

Male

Female

Marital Status(Required)

Country if not a U.S. Citizen(Required)

Visa Type(Required)

Tourist/Business

Work

Student

Exchange/Visitor

Ship Crew or Transit

Religious Worker Visa

Domestic Employee

Media/Journalist

Other

US State Born In(Required)

Country Born In(Required)

This field is hidden when viewing the form

</State born in controls>

Social Security Number(Required)

Green Card Number(Required)

Green Card Expiration Date(Required)

Driver's Licence(Required)

Yes

Drivers License Number

Driver's License State

Issue Date

Expiration Date

Prefer to upload an image or pdf of your Identity Documents instead?

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Upload your Driver's License, Social Security Card, Green Card and other identity documents here. Combined file size cannot exceed 25 mb.

Tax Planning Analysis

Drop files here or

Accepted file types: pdf, csv, xls, doc, docx, xlsx, jpg, png, Max. file size: 50 MB.

Please upload your most recent tax return if you would like us to provide you with a comprehensive tax return report to show you observations and uncover potential financial planning savings.

Additional Identity Documents

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Upload your Driver's License, Social Security Card, Green Card and other identity documents here. Combined file size cannot exceed 25 mb.

Current Home Address(Required)

Street Address Address Line 2 City State Abbreviation (2 letters only) ZIP / Postal Code Country

How long have you lived at your current address (in years)?(Required)

Previous Address(Required)

Street Address Address Line 2 City State Abbreviation (2 letters only) ZIP / Postal Code Country

Is your mailing address different than your home address?(Required)

No, my mailing address is my home address

Yes, my mailing address is my office address

Yes, my mailing address is another address

What shall we name your other address?(Required)

Mailing Address (if different than home address)(Required)

Street Address Address Line 2 City State Abbreviation (2 letters only) ZIP / Postal Code Country

Smoker Status(Required)

Current Smoker

Former Smoker

Non Smoker

Smoked in the last 12 Months?

Check if "Yes"

How long have you known the advisor?(Required)

Any hazardous sports/activities in the last 3 years?(Required)

Any foreign travel last year or the next two years? Specify location and dates.(Required)

Any tickets/accidents in the last 5 years?(Required)

Yes

If yes, provide details

Section II - Employment Information

Occupation/Title(Required)

Employer's Name(Required)

Years With Current Employer(Required)

Please enter a number from 0 to 75.

Current Employer Address(Required)

Street Address Address Line 2 City State Abbreviation (2 letters only) ZIP / Postal Code Country

Current Employer Phone(Required)

Previous Occupation(Required)

Years With Previous Employer(Required)

Please enter a number from 0 to 75.

Previous Employer's Name(Required)

Previous Employer's Duties(Required)

State of Previous Employment(Required)

Legal Company Name(Required)

Ownership of Policy (provide exact Business name or indicate same as above)(Required)

Beneficiary of Policy (provide exact Business name or indicate same as above)(Required)

Signer for the business shoud be(Required)

Business Tax ID Number(Required)

Company Address(Required)

Street Address Address Line 2 City State Abbreviation (2 letters only) ZIP / Postal Code Country

Industry(Required)

Year Established(Required)

# of Employees(Required)

Type of Organization(Required)

Sole Proprietorship

Partnership

LLC/LLP

Corporation

S Corp

Non Profit

Company Book Value

a. Total Assets(Required)

b. Total Liabilities(Required)

c. Total Net Worth(Required)

Company Market Value

a. Market Value(Required)

b. Insured percentage of Ownership(Required)

Please enter a number from 0 to 100.

c. Date of last format variation(Required)

Company Net Profit Before Taxes

a. Current Year(Required)

b. Last Year(Required)

List other currently insured Stockholders, Partners or Key Persons

1. Name(Required)

First Last

1. Title(Required)

1. Percentage Owned(Required)

Please enter a number from 0 to 100.

1. Insurance in Force (Dollars)(Required)

1. Insurance Applied For (Dollars)(Required)

2. Name(Required)

First Last

2. Title(Required)

2. Percentage Owned(Required)

Please enter a number from 0 to 100.

2. Insurance in Force (Dollars)(Required)

2. Insurance Applied For (Dollars)(Required)

3. Name(Required)

First Last

3. Title(Required)

3. Percentage Owned(Required)

Please enter a number from 0 to 100.

3. Insurance in Force (Dollars)(Required)

3. Insurance Applied For (Dollars)(Required)

4. Name(Required)

First Last

4. Title(Required)

4. Percentage Owned(Required)

Please enter a number from 0 to 100.

4. Insurance in Force (Dollars)(Required)

4. Insurance Applied For (Dollars)(Required)

Total Must Equal 100

Total Percentage Owned for Insured Stockholders, Partners or Key Persons

Does the business carry life insurance on the lives of any business officer(s) or partner(s)?

Yes

Purpose of Insurance (Select all that apply)

Key employee (List any special skills, knowledge or abilities possessed in Additional Details)

Stock redemption/Cross purchase

Loan guarantee coverage

Deferred Compensation

Other

Is there a written agreement?

Yes

Provide the date the agreement originated

Name of Lender

Purpose of Loan

Amount of Loan

Date of Loan

Years of Loan

Additional Details: Indicate section letter and question number.

Financial Information

Current Annual Tax Rate

Please enter a number from 0 to 100.

Prior Tax Year Income

Current Household Income(Required)

Liabilities(Required)

Assets(Required)

Net Worth(Required)

Individual Annual Income(Required)

Please enter a number greater than or equal to 0.

List Exact Duties

Full-time work for the past 3 months? If no, explain. (Disregard vacation days, and normal non-working days.)

What % of duties includes physical activity such as climbing, crouching, lifting?

Please enter a number from 0 to 100.

Weekly Working Hours:

Working at Residence

Yes

Working at Client Site

Yes

Clients seen in Residence?

Yes

Contact with outside customers?

Yes

Frequency of Contact

Choose 1 - Employment Status

W-2 Employee

Owner

Contract Employee

Self-Employed

Insured’s employer or business is a

Sole Proprietorship

Partnership

Limited Liability Co (LLC)

C Corp

S Corp

Other

Does the Insured have ownership interest in the business?

Yes

What %?

Please enter a number greater than or equal to 0.

How long has the Insured had ownership in this business? (yrs)

Does the insured supervise any employees?

Yes

How Many?

Premuim Paid By (Choose One)

Premium Paid By

Employer

Insured

Split % Between Employee/Employer

Employee %

Please enter a number from 0 to 100.

Employer %

Please enter a number from 0 to 100.

Payer SSN or Tax ID (If different from insured) #

Business Net Worth

Please enter a number greater than or equal to 0.

Revenue

Please enter a number greater than or equal to 0.

Year Established

# Of Employees

Total Company Assets

Please enter a number greater than or equal to 0.

Liabilities

Please enter a number greater than or equal to 0.

Net Profit: Previous Year:

Please enter a number greater than or equal to 0.

Net Profit: This Year:

Please enter a number greater than or equal to 0.

Does the Insured intend to change occupation, employer, or employment status?

Yes

Section III - Medical Information

Applicant 1

Past 2 years treated for Cancer, Heart Attack, Heart Disease, Chest Pain, Stroke, Alcohol/Drug Use, or Immune Disorder (not include HIV tests)?

Yes

Past 90 days admitted or advised to medical facility, or had surgery (except pregnancy)?

Yes

Next 90 days, any medical tests or examinations scheduled (except pregnancy related)?

Yes

Do you currently need assistance with any of the following everyday activities?

Bathing

Eating

Toileting

Dressing

Taking medication

Going from bed to chair

None of these

During the past 10 years, have you been medically diagnosed or treated for any of the following

Are you currently receiving Social Security Disability or Medi-Cal?

Yes

Do you currently use or have you used in the past 12 months

Walker

Wheelchair

Crutches

Braces

Motorized cart

Hospital bed

Oxygen

Cane

In past 12 months have you been advised to have any special testing or surgery that has not yet been performed?

Yes

Aware of any symptoms or complaints for which you plan to seek medical advice or treatment?

Yes

In past 12 months have you been hospitalized, received rehabilitative services including physical therapy, occupational therapy, home care or been confined to a nursing home or residential care facility?

Yes

In past 12 months have you received disability income or workers' compensation or any other state disability?

Yes

In past 5 years, have you had or been issued a handicap tag?

Yes

In past 5 years, have you been declined for long term care insurance?

Yes

In past 10 years, have you received medical advice, consultation, or treatment for the following conditions?

Substance Abuse

Alcoholism

Drug Dependency

Illicit Drug Use

Endocrine (Glandular) Disorders

Pituitary Adenoma

Pancreatitis

Diabetes

Addison’s Disease

Cushing’s Disease

Gastrointestinal Disorders

Hepatitis

Crohn’s Disease

Ulcerative Colitis

Liver Disease

Cancer

Basal Cell

Leukemia

Lymphoma

Melanoma

Sarcoma

Tumors

Circulatory Disorders

Genitourinary Disorders

Bladder Incontinence

Prostate Enlargement

Renal Failure

Renal Insufficiency

Musculoskeletal (bone or joint) Disorders

Blood Disorders

Anemia

Hemochromatosis

Polycythemia Vera

Thrombocytopenia

Eye Disorders

Glaucoma

Macular Degeneration

Retinitis Pigmentosa

Neurological Disorders

Respiratory Disorders

Asthma

Sarcoidosis

Chronic Bronchitis

Emphysema

Bronchiectasis

Chronic Obstructive Pulmonary Disease

Family (Mother, Father Siblings)

ALS (Lou Gehrig’s Disease)

Alzheimer’s Disease

Dementia

Heart Disease

Huntington’s Disease

Parkinson’s Disease

Polycystic Kidney Disease

Stroke

Height

Weight

In the past 5 years, have you consulted a Health Care Professional?

Yes

Physician's Contact Info

Primary Doctor

Primary Doctor Phone

Primary Doctor Address

Street Address Address Line 2 City State Abbreviation (2 letters only) ZIP / Postal Code Country

Primary Doctor Last Visit Date

Last Dr Visit Reason

List All Medications in the last 2 years (One per line)

List the medication name, the prescribing physician name and the dosage/frequency of use.

Health Concerns

Age of Mother

Age of Father

Parents Health History

General Information Applicant 2

Legal Name

First Last

DOB

US Citizen

Yes

Country (if not US)

State Born In

Marital Status

Gender

Social Security Number

Green Card Number

Drivers License Number

Driver's License State

Issue Date

Expiration Date

Prefer to upload an image or pdf of your Identity Documents instead?

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Upload your Driver's License, Social Security Card, Green Card and other identity documents here. Combined file size cannot exceed 50 mb.

Additional Identity Documents

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Upload your Driver's License, Social Security Card, Green Card and other identity documents here. Combined file size cannot exceed 50 mb.

Phone

Current Home Address

Street Address Address Line 2 City State Abbreviation (2 letters only) ZIP / Postal Code Country

Years at this address

Please enter a number from 0 to 100.

Former Address

Street Address Address Line 2 City State Abbreviation (2 letters only) ZIP / Postal Code Country

Occupation

Smoker (Past 12mo)

Yes

Height

Weight (lbs)

Individual Annual Income

Liabilities

Assets

Net Worth

Medical Information Applicant 2

Do you currently need assistance with any of the following everyday activities?

Bathing

Eating

Toileting

Dressing

Taking medication

Going from bed to chair

None of these

During the past 10 years, have you been medically diagnosed or treated for any of the following

Are you currently receiving Social Security Disability or Medi-Cal?

Yes

Do you currently use or have you used in the past 12 months

Walker

Wheelchair

Crutches

Braces

Motorized cart

Hospital bed

Oxygen

Cane

In past 12 months have you been advised to have any special testing or surgery that has not yet been performed?

Yes

Aware of any symptoms or complaints for which you plan to seek medical advice or treatment?

Yes

In past 12 months have you received disability income or workers' compensation or any other state disability?

Yes

In past 5 years, have you had or been issued a handicap tag?

Yes

In past 5 years, have you been declined for long term care insurance?

Yes

In past 10 years, have you received medical advice, consultation, or treatment for the following conditions?

Substance Abuse

Alcoholism

Drug Dependency

Illicit Drug Use

Endocrine (Glandular) Disorders

Pituitary Adenoma

Pancreatitis

Diabetes

Addison’s Disease

Cushing’s Disease

Gastrointestinal Disorders

Hepatitis

Crohn’s Disease

Ulcerative Colitis

Liver Disease

Cancer

Basal Cell

Leukemia

Lymphoma

Melanoma

Sarcoma

Tumors

Circulatory Disorders

Genitourinary Disorders

Bladder Incontinence

Prostate Enlargement

Renal Failure

Renal Insufficiency

Musculoskeletal (bone or joint) Disorders

Blood Disorders

Anemia

Hemochromatosis

Polycythemia Vera

Thrombocytopenia

Eye Disorders

Glaucoma

Macular Degeneration

Retinitis Pigmentosa

Neurological Disorders

Respiratory Disorders

Asthma

Sarcoidosis

Chronic Bronchitis

Emphysema

Bronchiectasis

Chronic Obstructive Pulmonary Disease

Family (Mother, Father Siblings)

ALS (Lou Gehrig’s Disease)

Alzheimer’s Disease

Dementia

Heart Disease

Huntington’s Disease

Parkinson’s Disease

Polycystic Kidney Disease

Stroke

In the past 5 years, have you consulted a Health Care Professional?

Yes

Physician's Contact Info

Primary Doctor

Primary Physician Address

Street Address Address Line 2 City State Abbreviation (2 letters only) ZIP / Postal Code