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PERSONAL AND CONFIDENTIAL
COMPLETED BY
DATE
GENERAL INFORMATION
Name
Date of Birth DD/MM/YYYY
Email
Phone
EMPLOYMENT
My Occupation
Business Name
ADDITIONAL INFORMATION
1. My Family
Number of Children Under Age 18
Number of Children Over Age 18
Other Dependents
2. My House
- Own Our House
- Renting
Other

MY OPINIONS
Please rate these items:
1. Saving and accumulating money on a regular basis is
- Very Important
- Important
- Of little value
2. Providing educational funds for children is
- Very Important
- Important
- Of little value
3. Having a professional advisor involved in my insurance, investment and retirement planning is
- Very Important
- Important
- Of little value
4. Developing and maintaining a strategic financial plan is
- Very Important
- Important
- Of little value
5. Having an up-to-date will and power of attorney is
- Very Important
- Important
- Of little value
6. In the event of my death or my spouse’s/partner’s premature death
a) maintaining our family’s lifestyle is
- Very Important
- Important
- Of little value
b) paying off any outstanding mortgage or debt is
- Very Important
- Important
- Of little value
c) providing for our children’s post-secondary education is
- Very Important
- Important
- Of little value
7. In the case of a disability or critical illness for me or my spouse/partner
a) being able to pay off the mortgage and other major bills is
- Very Important
- Important
- Of little value
b) maintaining our standard of living and lifestyle is
- Very Important
- Important
- Of little value
c) being able to pay for any additional medical expenses is
- Very Important
- Important
- Of little value
8. Minimizing the impact of inflation and taxes is
- Very Important
- Important
- Of little value
9. At retirement, having sufficient funds to retire on my own term is
- Very Important
- Important
- Of little value

IN THE NEAR FUTURE
I plan to or expect to:
1. Occupationally
- Receive a raise
- Change employment
- Start a business
- Retire
- Other
2. Personally
- Get married
- Start a family
- Care for a parent
- Other
3. Financially
- Buy/Sell a home/property
- Borrow money
- Pay off a loan
- Buy/Sell a business
- Other

FINANCIAL OVERVIEW
Please check the one most appropriate to you:
1. I have a professional advisor who guides me in my financial planning
- Yes
- No
- Not Sure
2. I know what I am entitled to under my and/or my spouse’s/partner’s group benefits and/or pension plan
- Yes
- No
- Not Sure
3 .I have a regular savings and accumulation program
- Yes
- No
- Not Sure
4. I have plans in place to provide post-secondary education for my children
- Yes
- No
- Not Sure
5 .I know how much income I will receive if I become disabled
- Yes
- No
- Not Sure
6. In the event of a critical illness (e.g., heart attack, cancer) I have enough money to make the necessary lifestyle adjustments
- Yes
- No
- Not Sure
7. I/We can afford the costs of long-term care should the need arise
- Yes
- No
- Not Sure

RETIREMENT OVERVIEW
Please check the one most appropriate to you:
1. I know what capital I need now to be on a permanent vacation during my retirement years
- Yes
- No
- Not Sure
2. My pension plan/retirement fund is structured to maximize its benefits
- Yes
- No
- Not Sure
3. I maximize my RRSP contributions each year
- Yes
- No
- Not Sure
4. My current rate of savings and investments are sufficient to meet my retirement objectives
- Yes
- No
- Not Sure
5. I understand what happens to my group benefits at retirement
- Yes
- No
- Not Sure

ESTATE OVERVIEW
Please check the one most appropriate to you:
1. I/We have made a list of all important documents and their location
- Yes
- No
- Not Sure
2 .I understand the full impact of how taxes will be applied to my estate and those ramifications
- Yes
- No
- Not Sure
3. I have an up-to-date will and power of attorney
- Yes
- No
- Not Sure
4. My/Our current life insurance coverage will sustain our family’s lifestyle after my death
- Yes
- No
- Not Sure

I AM INTERESTED IN DISCUSSING / REVIEWING
1. A review of my savings and investment programs
- Yes
- No
2. Ways to maximize my pension and retirement income
- Yes
- No
3. Ways to fund post secondary education for my children or grandchildren
- Yes
- No
4. Ways to put an up-to-date financial plan in place
- Yes
- No
5. Ways to maintain my family’s lifestyle in the event of my death or disability
- Yes
- No
6. Ways to maximize charitable gifting
- Yes
- No
7. Strategies to reduce taxes
- Yes
- No
8. Insurance to pay off the mortgage
- Yes
- No
9. Ways to offset the cost of a critical illness
- Yes
- No
10. Ways to offset the substantial expense of long term care
- Yes
- No
11. Ways to fund Capital Gains and other estate taxes
- Yes
- No
12. Ways to ensure the value of my business goes to my family should I die, become disabled or critically ill
- Yes
- No
13. Life insurance on (check accordingly)
- Myself
- My spouse/partner
- My children/grandchildren
14. Income protection (Disability) (check accordingly)
- Myself
- My spouse/partner
- My children/grandchildren
15. Critical Illness Insurance on (check accordingly)
- Myself
- My spouse/partner
- My children/grandchildren
16. Long Term Care Insurance (check accordingly)
- Myself
- My spouse/partner
- My children/grandchildren

NOTES, COMMENTS, REFERRALS

This post is also available in: FR

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