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)

Hidden

</State born in controls>

Social Security Number(Required)

Green Card Number(Required)

Green Card Expiration Date(Required)

Drivers License Number(Required)

Driver's License State(Required)

Issue Date(Required)

Expiration Date(Required)

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 Country

Last 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.

Section IV - INFORCE LONG TERM CARE (Applicant 1)

1. Have a policy, certificate or application with this or any other company providing long term care insurance?

Yes

2. Have another long-term care insurance policy or certificate in force during the past 12 months?

Yes

Lapse Date

Q#1 Company

Q1 Policy#

Q1 Date

Q1 Amount

Q1 Do you intend to replace this policy?

Yes

Q#2 Company

Q2 Policy#

Q2 Date

Q2 Amount

Q2 Do you intend to replace this policy?

Yes

Q#3 Company

Q3 Policy#

Q3 Date

Q3 Amount

Q3 Do you intend to replace this policy?

Yes

Section IV - INFORCE LONG TERM CARE (Applicant 2)

4. Have a policy, certificate or application with this or any other company providing long term care insurance?

Yes

5. Have another long-term care insurance policy or certificate in force during the past 12 months?

Yes

Lapse Date

6. Intend to replace any of your long-term care, medical or health insurance coverage with this policy?

Yes

Q#4 Company

Q4 Policy#

Q4 Date

Q4 Amount

Q4 Do you intend to replace this policy?

Yes

Q#5 Company

Q5 Policy#

Q5 Date

Q5 Amount

Q5 Do you intend to replace this policy?

Yes

Q#6 Company

Q6 Policy#

Q6 Date

Q6 Amount

Q6 Do you intend to replace this policy?

Yes

Section IV - INFORCE DISABILITY INSURANCE

Does the Applicant have any Group Coverage and/or other DI in force, pending, or contemplated with other Companies?

Yes

Company

Amount

Issue Year

Policy #

Plan Type

Are we replacing existing coverage?

Yes

Existing coverage details.

Have you ever had Life, Disability, or Health insurance declined, canceled, or not renewed?

Yes

Company

Reason for Decline or Rating

Date of Decline or Rating

Last exam or application for Life, Disability, or Accidental Death insurance? Month (enter 01-12)

Last exam or application for Life, Disability, or Accidental Death insurance? Year

Company

Section IV - INFORCE LIFE INSURANCE

Does the applicant have INFORCE LIFE INSURANCE?

Yes

How many INFORCE LIFE INSURANCE POLICIES?

INFORCE Policy 1: Company Name

INFORCE Policy 1: Amount

INFORCE Policy 1: Policy #

INFORCE Policy 1: Issue Year

INFORCE Policy 1: Plan Type

Inforce Policy 1: Do you intend to replace this policy?

Yes

INFORCE Policy 2: Company Name

INFORCE Policy 2: Amount

INFORCE Policy 2: Policy #

INFORCE Policy 2: Plan Type

INFORCE Policy 2: Issue Year

Inforce Policy 2: Do you intend to replace this policy?

Yes

INFORCE Policy 3: Company Name

INFORCE Policy 3: Amount

INFORCE Policy 3: Policy #

INFORCE Policy 3: Issue Year

INFORCE Policy 3: Plan Type

Inforce Policy 3: Do you intend to replace this policy?

Yes

INFORCE Policy 4: Company Name

INFORCE Policy 4: Amount

INFORCE Policy 4: Policy #

INFORCE Policy 4: Issue Year

INFORCE Policy 4: Plan Type

Inforce Policy 4: Do you intend to replace this policy?

Yes

INFORCE Policy 5: Company Name

INFORCE Policy 5: Amount

INFORCE Policy 5: Policy #

INFORCE Policy 5: Issue Year

INFORCE Policy 5: Plan Type

Inforce Policy 5: Do you intend to replace this policy?

Yes

Is this a replacement of coverage from another company?

Yes

Replacement Company Name

Have you ever been declined or rated by another company?

Yes

Declining Company Name

Reason for decline or rating

Decline Date

Section V - OWNER

Who owns the policy?

Insured Owned

Other Owner

Trust Owned

Other Owner Name

First Last

Other Owner Social Security #

Other Owner Phone

Other Owner DOB

Other Owner Address

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

Relationship to Insured

INVESTMENTS

Employment Status

Employer Name/Business Name

Hidden

(DNU) Are you or an immediate family member associated with or employed by a stock exchange or member firm of an exchange or FINRA, or a municipal securities broker-dealer?

Yes

INV - Are you or an immediate family member associated with or employed by a stock exchange or member firm of an exchange or FINRA, or a municipal securities broker-dealer?

Yes

Broker/Firm Name

Attach Broker Approval

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

* If "Yes," you must attach a letter from your or your immediate family member's employer or affiliated broker-dealer approving the establishment of your account when submitting this application.

Form is Attached

Hidden

OLD DNU Are you a director, 10% shareholder or policy-making officer of a publicly held company?

Yes

INV - Are you a director, 10% shareholder or policy-making officer of a publicly held company?

Yes

Enter company name and trading symbol

Optional:

Link a bank checking account to the investment account (Schwab Money Link)

Bank Name

Account Title on Bank Account

Is this a business checking account?

Yes

Please upload a banker signed letter on their letterhead stating account number, routing number, title, and list of who is account owner and an authorized signer.

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

Bank Routing Number

Bank Account Number

Name of authorized signer 1

First Last

Phone Authorized Signer 1

Email Authorized Signer 1

Name of authorized signer 2

First Last

Phone Authorized Signer 2

Email Authorized Signer 2

Optional:

-Trusted Contact (not a beneficiary but just a person that you authorize your brokerage firm to contact in limited circumstances, such as if your broker has trouble reaching you or has a reasonable belief that your account may be exposed to possible financial exploitation. A trusted contact person must be age 18 or older)

Trusted Contact Name

First Last

Trusted Contact Phone

Trusted Contact Email

Trusted Contact Relationship

Investment - Joint Account

Investment - Corporate Account

Hidden

Section Break

How many joint applicants or members?

Joint Applicant/Member 1

Name

First Last

SS#

DOB

Address

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

Is your mailing address Different?

Yes

Mailing Address (if different)

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

Phone

Country of Residence

Country of Citizenship

Employment Status

Employer Name/Business Name

Hidden

DNU Are you or an immediate family member associated with or employed by a stock exchange or member firm of an exchange or FINRA, or a municipal securities broker-dealer?

Yes

JA1 -Are you or an immediate family member associated with or employed by a stock exchange or member firm of an exchange or FINRA, or a municipal securities broker-dealer?

Yes

Broker/Firm Name

Attach Broker Approval

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

* If "Yes," you must attach a letter from your or your immediate family member's employer or affiliated broker-dealer approving the establishment of your account when submitting this application.

Form is Attached

Hidden

DNU Are you a director, 10% shareholder or policy-making officer of a publicly held company?

Yes

JA1 -Are you a director, 10% shareholder or policy-making officer of a publicly held company?

Yes

Enter company name and trading symbol

Hidden

</ JA1>

Hidden

< Corporate JA1>

Role

Authorized Person

Control Person

Greater than 10% Beneficial Owner

% Owned

Please enter a number from 10 to 100.

Title or Capacity

Hidden

</Corporate JA1>

Joint Applicant/Member 2

Name

First Last

SS#

DOB

Address

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

Is your mailing address Different?

Yes

Mailing Address (if different)

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

Phone

Country of Residence

Country of Citizenship

Employment Status

Employer Name/Business Name

Hidden

DNU Are you or an immediate family member associated with or employed by a stock exchange or member firm of an exchange or FINRA, or a municipal securities broker-dealer?

Yes

JA2 - Are you or an immediate family member associated with or employed by a stock exchange or member firm of an exchange or FINRA, or a municipal securities broker-dealer?

Yes

Broker/Firm Name

Attach Broker Approval

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

* If "Yes," you must attach a letter from your or your immediate family member's employer or affiliated broker-dealer approving the establishment of your account when submitting this application.

Form is Attached

Hidden

DNU Are you a director, 10% shareholder or policy-making officer of a publicly held company?

Yes

JA2 -Are you a director, 10% shareholder or policy-making officer of a publicly held company?

Yes

Enter company name and trading symbol

Hidden

</ JA2>

Hidden

< Corporate JA2>

Role

Authorized Person

Control Person

Greater than 10% Beneficial Owner

% Owned

Please enter a number from 10 to 100.

Title or Capacity

Hidden

</Corporate JA2>

Joint Applicant/Member 3

Name

First Last

SS#

DOB

Address

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

Is your mailing address Different?

Yes

Mailing Address (if different)

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

Phone

Country of Residence

Country of Citizenship

Employment Status

Employer Name/Business Name

Hidden

DNU Are you or an immediate family member associated with or employed by a stock exchange or member firm of an exchange or FINRA, or a municipal securities broker-dealer?

Yes

JA3 - Are you or an immediate family member associated with or employed by a stock exchange or member firm of an exchange or FINRA, or a municipal securities broker-dealer?

Yes

Broker/Firm Name

Attach Broker Approval

Max. file size: 50 MB.

* If "Yes," you must attach a letter from your or your immediate family member's employer or affiliated broker-dealer approving the establishment of your account when submitting this application.

Form is Attached

Hidden

DNU Are you a director, 10% shareholder or policy-making officer of a publicly held company?

Yes

JA3 -Are you a director, 10% shareholder or policy-making officer of a publicly held company?

Yes

Enter company name and trading symbol

Hidden

</ JA3>

Hidden

<Corporate JA3>

Role

Authorized Person

Control Person

Greater than 10% Beneficial Owner

% Owned

Please enter a number from 10 to 100.

Title or Capacity

Hidden

</Corporate JA3>

Joint Applicant/Member 4

Name

First Last

SS#

DOB

Address

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

Is your mailing address Different?

Yes

Mailing Address (if different)

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

Phone

Country of Residence

Country of Citizenship

Employment Status

Employer Name/Business Name

Hidden

DNU Are you or an immediate family member associated with or employed by a stock exchange or member firm of an exchange or FINRA, or a municipal securities broker-dealer?

Yes

JA4 -Are you or an immediate family member associated with or employed by a stock exchange or member firm of an exchange or FINRA, or a municipal securities broker-dealer?

Yes

Broker/Firm Name

Attach Broker Approval

Max. file size: 50 MB.

* If "Yes," you must attach a letter from your or your immediate family member's employer or affiliated broker-dealer approving the establishment of your account when submitting this application.

Form is Attached

Hidden

DNU Are you a director, 10% shareholder or policy-making officer of a publicly held company?

Yes

JA4 -Are you a director, 10% shareholder or policy-making officer of a publicly held company?

Yes

Enter company name and trading symbol

Hidden

</ JA4>

Hidden

<Corporate JA4>

Role

Authorized Person

Control Person

Greater than 10% Beneficial Owner

% Owned

Please enter a number from 10 to 100.

Title or Capacity

Hidden

</Corporate JA4>

Joint Applicant/Member 5

Name

First Last

SS#

DOB

Address

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

Is your mailing address Different?

Yes

Mailing Address (if different)

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

Phone

Country of Residence

Country of Citizenship

Employment Status

Employer Name/Business Name

Hidden

DNU Are you or an immediate family member associated with or employed by a stock exchange or member firm of an exchange or FINRA, or a municipal securities broker-dealer?

Yes

JA5 - Are you or an immediate family member associated with or employed by a stock exchange or member firm of an exchange or FINRA, or a municipal securities broker-dealer?

Yes

Broker/Firm Name

Attach Broker Approval

Max. file size: 50 MB.

* If "Yes," you must attach a letter from your or your immediate family member's employer or affiliated broker-dealer approving the establishment of your account when submitting this application.

Form is Attached

Hidden

DNU Are you a director, 10% shareholder or policy-making officer of a publicly held company?

Yes

JA5 - Are you a director, 10% shareholder or policy-making officer of a publicly held company?

Yes

Enter company name and trading symbol

Hidden

</ JA5>

Hidden

<Corporate JA5>

Role

Authorized Person

Control Person

Greater than 10% Beneficial Owner

% Owned

Please enter a number from 10 to 100.

Title or Capacity

Hidden

</Corporate JA5>

Hidden

</ Joint Applicants>

Type of joint tenancy

Community property

Community property w/right of survivorship

Joint tenants w/right of survivorship

Tenants by entirety

Tenants in common

Tenancy State

% of Tenancy Ownership - Individual 1

Please enter a number from 0 to 100.

% of Tenancy Ownership - Individual 2

Please enter a number from 0 to 100.

% of Tenancy Ownership - Individual 3

Please enter a number from 0 to 100.

% of Tenancy Ownership - Individual 4

Please enter a number from 0 to 100.

% of Tenancy Ownership - Individual 5

Please enter a number from 0 to 100.

UTMA/UGMA Account

Minor Owner - Name

First Last

Minor Owner - DOB

Minor Owner SSN/Tax ID Number

Under laws of which state

Age of Termination

(Typically 18 or 21, but can be up to age 25 in CA, AK, FL, NV)

Traditional IRA, Rollover IRA, Roth IRA Account

IRA Account Type

Traditional IRA

Rollover IRA

Roth IRA

Add Beneficiaries or Trust

Add Beneficiaries

Add Trust

Hidden

Is client taking RMDs?

Is client currently taking RMDs

Yes

RMD Info

How would client like Required Minimum Distributions (RMD) sent

Physical check mailed to address of record (default)

RMD amount sent electronically via ACH to their linked bank (must link a bank first)

RMD amount sent to another non-retirement Schwab account

Does client want Federal Tax withheld from RMD distribution

Yes

What Percentage?

Please enter a number from 0 to 100.

Does client want State Tax withheld from RMD distribution

Yes

What Percentage?

Please enter a number from 0 to 100.

Inherited IRA Account

Add Beneficiaries or Trust

Add Beneficiaries

Add Trust

Date of birth of original IRA depositor (decedent)

Date of death of original IRA depositor (decedent)

Simple or SEP-IRA Account

Is SEP a passthrough entity i.e. under SSN of account owner

Yes

Employer Tax ID of the company sponsoring the plan

529 Account

Individual Transfer on Death Account

Joint Tenant Transfer on Death Account

Hidden

Section Break

Add Beneficiaries or Trust

Add Beneficiaries

Add Trust

Corporate Account

Corporation Name

If corporation is known by another name, enter name

Type of Organization

C Corporation

Nonprofit/Charitable Organization

S Corporation

Corporation Tax ID number

List all members who are greater than or equal to 10% owner of the corporation

(One per line, %)

Corporation Address

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

Is the mailing address of the corporation different than listed above?

Yes

Corporation Mailing Address (if different)

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

Country of Incorporation

State of Incorporation

Date of Incorporation

Advisor Alert

Articles of Incorporation (Upload)

Max. file size: 50 MB.

Alert Received

Copy of the Articles of Incorporation Uploaded

Copy of the Articles of Incorporation Not Uploaded

We will need a Copy of the Articles of Incorporation

Hidden

</ Corporate Section>

Company Retirement Account: Solo 401(k), Profit Sharing, DB Pension Plan Account

Type of Plan Account Being Opened

Solo 401(k)

Profit Sharing

DB Pension Plan Account

Company Business Structure

Company Name

Company Phone Number

Employer Tax ID of the company sponsoring the plan

Country of Legal Establishment

State of Legal Establishment

Plan Name

Plan Tax ID#

Plan Effective Date

Advisor Alert

401(k) Plan Document (Upload)

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

Alert Received

Copy of the 401(k) Plan Document Uploaded

Copy of the 401(k) Plan Document Not Uploaded

We will need a Copy of the 401(k) Plan Document

Hidden

</ Company Retirement Account>

Trust/Trustees

How many Trustees?

One

Two

Three

How many Trusts?

One

Two

Three

Trustee 1

Trustee 1 Full Legal Name Trust exactly as it appears on your Trust document

Trustee 1 Date Established

Certification of Trustee/Trust 1 Copy

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

Trustee 1 Name

Trustee 1 SSN#

Trustee 1 Distribution Percentage

Please enter a number from 0 to 100.

Trust 1 Grantor

Trust 1 Grantor Email

Trust Grantor 1 Relationship

Trustee 2

Trustee 2 Full Legal Name Trust exactly as it appears on your Trust document

Trustee 2 Date Established

Certification of Trust/Trust 2 Copy

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

Trustee 2 Name

Trustee 2 SSN#

Trustee 2 Distribution Percentage

Please enter a number from 0 to 100.

Trust 2 Grantor

Trust 2 Grantor Email

Trust Grantor 2 Relationship

Hidden

Trust Grantor 2 Relationship - hidden DNU

Trustee 3

Trustee 3 Full Legal Name Trust exactly as it appears on your Trust document

Trust 3 Date Established

Certification of Trust/Trust 3 Copy

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

Trustee 3 Name

Trustee 3 SSN#

Trustee 3 Distribution Percentage

Please enter a number from 0 to 100.

Trust 3 Grantor

Trust 3 Grantor Email

Trust Grantor 3 Relationship

Hidden

Trust Grantor 3 Relationship HIDDEN DNU

Trust 1

Trust 1 Full Legal Name of Trust exactly as it appears on your Trust document

Trust Date Established

Certification of Trust/Trust Copy

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

Trustee Name

Trustee SSN#

Trustee Distribution Percentage

Please enter a number from 0 to 100.

Trust Grantor

Trust Grantor Email

Trust Grantor Relationship

Trust 2

Trust 2 Full Legal Name of Trust exactly as it appears on your Trust document

Trust Date Established

Certification of Trust/Trust Copy

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

Trustee Name

Trustee SSN#

Trustee Distribution Percentage

Please enter a number from 0 to 100.

Trust Grantor

Trust Grantor Email

Trust Grantor Relationship

Trust 3

Trust 3 Full Legal Name of Trust exactly as it appears on your Trust document

Trust Date Established

Certification of Trust/Trust Copy

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

Trustee Name

Trustee SSN#

Trustee Distribution Percentage

Please enter a number from 0 to 100.

Trust Grantor

Trust Grantor Email

Trust Grantor Relationship

Beneficiaries

BENEFICIARIES

How Many Beneficiaries?(Required)

One

Two

Three

Four

Beneficiary 1

Beneficiary 1 Name(Required)

Beneficiary 1 Date of Birth(Required)

Beneficiary 1 SSN/TaxID(Required)

Beneficiary 1 Relationship(Required)

Beneficiary 1 Distribution Percentage(Required)

Please enter a number from 0 to 100.

Beneficiary 1 Email(Required)

Beneficiary 2

Beneficiary 2 Name(Required)

Beneficiary 2 Date of Birth(Required)

Hidden

Beneficiary 2 Relationship (Hidden, Don't Use Will Delete)

Beneficiary 2 SSN/TaxID(Required)

Beneficiary 2 Relationship(Required)

Beneficiary 2 Distribution Percentage(Required)

Please enter a number from 0 to 100.

Beneficiary 2 Email(Required)

Contingent Beneficiary 1

Contingent Beneficiary 1 Name(Required)

Contingent Beneficiary 1 Date of Birth(Required)

Hidden

Contingent Beneficiary 1 Relationship (HIDDEN DNU)

Contingent Beneficiary 1 SSN/TaxID(Required)

Contingent Beneficiary 1 Relationship(Required)

Contingent Beneficiary 1 Distribution Percentage(Required)

Please enter a number from 0 to 100.

Contingent Beneficiary 1 Email(Required)

Contingent Beneficiary 2

Contingent Beneficiary 2(Required)

Contingent Beneficiary 2 Date of Birth(Required)

Hidden

Contingent Beneficiary 2 Relationship (HIDDEN DNU)

Contingent Beneficiary 2 SSN/TaxID(Required)

Contingent Beneficiary 2 Relationship(Required)

Contingent Beneficiary 2 Distribution Percentage(Required)

Please enter a number from 0 to 100.

Contingent Beneficiary 2 Email(Required)

Custodian for child(ren)

Custodial State

Trust Account

Trust type

Revocable trust: where all Grantor(s) Current Trustee(s) and Current Beneficiary(ies) are the same individual(s)

Other Revocable Trust: Notarization of Trustees’ signatures is required

Irrevocable Trust: Notarization of Trustees’ signatures is required AND Tax-exempt Trusts must provide proof of exempt status, such as a Tax Declaration Letter

Testamentary Trust (created through probate or will only) Notarization of Trustees’ signatures is required

Check appropriate box if the Irrevocable trust is a:

GRAT

CRUT

CRAT

Certification of Trust/Trust Copy

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

Decedent’s name

First Last

Country governing the trust

State governing the trust

Advisor Alert

Alert Received

Certification of Trust/Trust Copy Uploaded

Certification of Trust/Trust Copy Not Uploaded

We will need a Copy of the Certification of Trust (or first pages showing Trust title, and last page(s) with trustee and notary dated signatures)

Hidden

Populate USA as Country for Salesforce(Required)

Hidden

Populate USA as Country for Salesforce(Required)

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