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The Affluent Insurance Advisor

Life Insurance Design Questionaire

Thank you for your interest in learning more about The Affluent Insurance Advisor, LLC, and how we can help you make the very best decisions to secure the financial future of your family and other loved ones.

To begin the process, kindly complete the intake form that appears below. If you are unsure of a response, that's okay, feel free to continue to the next question.

Once you are done, please click the "Submit" button and a member of our executive team will contact you to schedule an appointment.

Personal Information

Advisor Name:


Advisor Phone:

Individual's Name:

Date Of Birth:




Nicotine Use:






Has your health changed since your current policy was issued?

   Yes No

Spouse Information

Spouse's Name:

Date Of Birth:




Nicotine Use:






Has your spouse's health changed since your current policy was issued?

   Yes No

Current Policy Information

What is the total current life insurance in-force?

Is this policy:

   Single Life Joint Life

What is the reason this life insurance was purchased? (Check One)

Survivor Needs Business Continuation Key Person Protection
Estate Planning Retirement Income Other

Has this reason changed? If yes, please provide details.

Briefly describe the purpose of this life insurance:

Current Priorities and Insurance Policy

Life insurance policies involve trade-offs between performance, guarantees and low initial premiums.

In some cases, it is possible to get two of these together, but no policy can offer all three simultaneously.


Prioritize these objectives in order of their importance to you:

I want the best potential in the long term
I want the strongest possible guarantee
I want to pay the lowest possible premium

Name of the current company:


Policy Number:

Owner of the policy:

If owned by a trust, provide names of trustees & relationship to insured:

Policy beneficiary:


Policy issue date:

Type of policy: (Check One)

Universal Life Variable Universal Life Term
Group Term Participating Whole Life Non-participating Whole Life
Graded Premium Other

Current death benefit ($):


Current billed premium ($):

Current cash surrender value ($):


Current premium being paid ($):

Cost basis if known ($):


Is this policy a MEC?

Yes No

Are there any loans on the existing contract?

Yes No

If Yes, please enter the loan amount ($):

Looking Forward Perspective

Primary concern if improvement is advisable:

Increase Death Benefit Reduction in Premium Extend Coverage Duration

How much death benefit is required at this time?

Amount ($):


Avoid modified endowment contract (MEC) statute:

Yes No

If using Variable Life, what hypothetical gross rate?

How long will you require the death benefit coverage?

Today Life Expectancy Age 100 Beyond 100

How many years do you wish to pay premiums?

1 Year 5 Years 10 Years Life Expectancy All Years

Company quality: What percentile ranking would you prefer?

Top 5% Top 10% Top 20% Top 50% All Companies

Other Specifications


Premium flexibility?

Increasing death benefit need?