Discovery Questionnaire – Role Model Agency

Order Number

Agents Name

What are the top three financial goals you want and by when?

Enable

Financial Goal 1

Financial Goal 2

Financial Goal 3

Date

CLIENT PROFILE

CLIENT’S MARITAL STATUS *

SINGLE MARRIED WIDOWED DIVORCED

Client

Significant Other

First Name

Significant Other First Name

Middle Name

Significant Other Middle Name

Last Name

Significant Other Last Name

Birth Date (must be 18+)

DOB

Significant Other DOB

Nationality (Country Citizenship)

Nationality

Significant Other Nationality

SSN

Significant Other SSN

Email Address

Significant Other Email

Telephone (Cell) No.

Phone Number

Significant Other Phone Number

Street Address, Apt #. PO Box

Address

Significant Other Address

City, State, Zip Code, Country

Significant Other City, State, Zip Code, Country

Driver’s License No. / State

Significant Other Driver’s License No. / State

Emergency Contacts

Contact Person 1

Contact Person 2

Full Name

Contact Person 1 Full Name

Contact Person 2 Full Name

Relationship

Contact Person 1 Relationship

Contact Person 2 Relationship

Telephone/Cell Phone No.

Contact Person 1 Telephone

Contact Person 2 Telephone

Email Address

Contact Person 1 Email Address

Contact Person 2 Email Address

Street Address, Apt #. PO Box

Contact Person 1 Street Address

Contact Person 2 Street Address

City, State, Zip Code, Country

Contact Person 1 City, State, Zip Code, Country

Contact Person 2 City, State, Zip Code, Country

Employment

Client

Significant Other

Employed By

Other Employed By

Years Employed

No. of Years

Other No. of Years

Occupation

Client Occupation

Other Occupation

Annual Income

Client Annual Income

Other Annual Income

Employer Street Address

Street Address

Other Street Address

City, State, Zip Code, Country

Employer City, State, Zip Code, Country

City, State, Zip Code, Country (Other)

MEDICAL HISTORY

Client Information

Physician Name

Physician/Clinic Address

Name of Clinic

Clinic Phone No.

Medical Conditions and Date diagnosed

Surgery/Hospitalization in past 10 years

Mother’s Maiden Name

Smoker:

Yes No

Height

Weight

Client’s Medication Name

Client’s Medication Name 1

Client’s Medication Name 2

Client’s Medication Name 3

Client’s Medication Name 4

Client’s Medication Name 5

Client’s Medication Name 6

Dosage ML

Dosage ML 1

Dosage ML 2

Dosage ML 3

Dosage ML 4

Dosage ML 5

Dosage ML 6

Frequency

Frequency 1

Frequency 2

Frequency 3

Frequency 4

Frequency 5

Frequency 6

Reason for prescription

Reason for prescription 1

Reason for prescription 2

Reason for prescription 3

Reason for prescription 4

Reason for prescription 6

Significant Other Medical History

Physician Name

Physician/Clinic Address

Name of Clinic

Clinic Phone No.

Medical Conditions and date diagnosed

Surgery/Hospitalization in past 10 years

Mother’s Maiden Name

Smoker:

Yes No

Height

Weight

Significant Other Medication Name

Significant Other Medication Name 1

Significant Other Medication Name 2

Significant Other Medication Name 3

Significant Other Medication Name 4

Significant Other Medication Name 5

Significant Other Medication Name 6

Dosage ML

Dosage ML 1

Dosage ML 2

Dosage ML 3

Dosage ML 4

Dosage ML 5

Dosage ML 6

Frequency

Frequency 1

Frequency 2

Frequency 3

Frequency 4

Frequency 5

Frequency 6

Reason for prescription

Reason for prescription 1

Reason for prescription 2

Reason for prescription 3

Reason for prescription 4

Reason for prescription 5

Reason for prescription 6

FUNERAL ASSISTANCE PLAN

Member Information

Member 1 First Name

Member 1 Last Name

Member 1 Relationship to Owner

Member 1 Birth Date (must be 18+)

Member 1 City, State, Country

Member 1 Preferred Funeral Home

Member 2 First Name

Member 2 Last Name

Member 2 Relationship to Owner

Member 2 Birth Date (must be 18+)

Member 2 City, State, Country

Member 2 Preferred Funeral Home

Member 3 First Name

Member 3 Last Name

Member 3 Relationship to Owner

Member 3 Birth Date (must be 18+)

Member 3 City, State, Country

Member 3 Preferred Funeral Home

Member 4 First Name

Member 4 Last Name

Member 4 Relationship to Owner

Member 4 Birth Date (must be 18+)

Member 4 City, State, Country

Member 4 Preferred Funeral Home

Member 5 First Name

Member 5 Last Name

Member 5 Relationship to Owner

Member 5 Birth Date (must be 18+)

Member 5 City, State, Country

Member 5 Preferred Funeral Home

*If you want funeral protection for more than 5 family, friends or pets, additional fees will apply. Please, add their information to notes.

CURRENT LIFE INSURANCE

Policy Details

Policy 1

Policy 2

Policy 3

Company

Policy 1 Company

Policy 2 Company

Policy 3 Company

Type

Policy 1 Type

Policy 2 Type

Policy 3 Type

Date Issued

Policy 1 Date Issued

Policy 2 Date Issued

Policy 3 Date Issued

Death Benefits

Death Benefits (Policy 1)

Death Benefits (Policy 2)

Death Benefits (Policy 3)

Reduced Paid Up Option

Reduced Paid Up Option (Policy 1)

Reduced Paid Up Option (Policy 2)

Reduced Paid Up Option (Policy 3)

Cash Value

Cash Value (Policy 1)

Cash Value (Policy 2)

Cash Value (Policy 3)

Loans

Loans (Policy 1)

Loans (Policy 2)

Loans (Policy 3)

Purpose

Purpose (Policy 1)

Purpose (Policy 2)

Purpose (Policy 3)

INSURANCE

TYPE

CARRIER

PREMIUM

Health

Health (Carrier)

Health (Premium)

Disability

Disability (Carrier)

Disability (Premium)

Long Term Care

Long Term Care (Carrier)

Long Term Care (Premium)

ESTATE PLANNING DOCS

Will & Living Will

Yes No

Last Date Updated

Trust

Yes No

Date Updated

Power of Attorney

Yes No

POA First & Last Name

FICO Score

ID Theft Protection

Yes No

ESTATE PLANNING DOCS

Will & Living Will

Yes No

Last Date Updated

Trust

Yes No

Date Updated

Power of Attorney

Yes No

POA First & Last Name

FICO Score

ID Theft Protection

Yes No

Who has access to your secure passwords, documents (i.e., Apple ID, mobile banking, cryptocurrency, will, trust, policies)?

Do you own a Legacy Vault?

Yes No

Do you own a final wishes planner?

Yes No

Do you own a fireproof safe?

Yes No

MORTGAGE DEBT

Lender Name

Mortgage Start Date

Mortgage Term

Monthly Payment

Lender Name 1

Mortgage Start Date 1

Mortgage Term 1

Monthly Payment 1

Lender Name 2

Mortgage Start Date 2

Mortgage Term 2

Monthly Payment 2

Lender Name 3

Mortgage Start Date 3

Mortgage Term 3

Monthly Payment 3

Extra Principal Payment

Interest Rate

Escrow Payment

Mortgage Insurance Payment

Extra Principal Payment 1

Interest Rate 1

Escrow Payment 1

Mortgage Insurance Payment 1

Extra Principal Payment 2

Interest Rate 2

Escrow Payment 2

Mortgage Insurance Payment 2

Extra Principal Payment 3

Interest Rate 3

Escrow Payment 3

Mortgage Insurance Payment 3

Current Mortgage Balance

Original Mortgage Amount

*Including Principal, Interest, Escrows, PMI/Mortgage Insurance etc.

LOAN DEBT

Account Name

Loan Start Date

Loan Term

Monthly Payment

Account Name 1

Loan Start Date 1

Loan Term 1

Monthly Payment 1

Account Name 2

Loan Start Date 2

Loan Term 2

Monthly Payment 2

Account Name 3

Loan Start Date 3

Loan Term 3

Monthly Payment 3

Extra Principal Payment 1

Interest Rate 1

Current Loan Balance

Original Loan Amount

Extra Principal Payment 2

Interest Rate 2

Current Loan Balance 1

Original Loan Amount 1

Extra Principal Payment 3

Interest Rate 3

Current Loan Balance 2

Original Loan Amount 2

Extra Principal Payment 4

Interest Rate 4

Current Loan Balance 3

Original Loan Amount 3

* Auto Loans, Student Loans, Personal Loans, Business Loans

REVOLVING DEBT

Type of Credit

Current Balance

Minimum Payment

Extra Principal Payment

Type of Credit 1

Current Balance 1

Minimum Payment 1

Extra Principal Payment 1

Type of Credit 2

Current Balance 2

Minimum Payment 2

Extra Principal Payment 2

Type of Credit 3

Current Balance 3

Minimum Payment 3

Extra Principal Payment 3

Interest Rate

Credit Limit

ASSETS

Asset

Vendor/Firm

Balance

Installment

Mode

Stocks

Vendor/Firm Stocks

Balance (Stocks)

Installment (Stocks)

Mode (Stocks)

Bonds

Vendor/Firm Bonds

Balance (Bonds)

Installment (Bonds)

Mode (Bonds)

401K

Vendor/Firm 401K

Balance (401K)

Installment (401K)

Mode (401K)

403b/457

Vendor/Firm 403b/457

Balance (403b/457)

Installment (403b/457)

Mode (403b/457)

Savings

Vendor/Firm Savings

Balance (Savings)

Installment (Savings)

Mode (Savings)

Money Market

Vendor/Firm Money Market

Balance (Money Market)

Installment (Money Market)

Mode (Money Market)

Vendor/Firm CD

Balance (CD)

Installment (CD)

Mode (CD)

IRA

Vendor/Firm IRA

Balance (IRA)

Installment (IRA)

Mode (IRA)

Real Estate

Vendor/Firm Real Estate

Balance (Real Estate)

Installment (Real Estate)

Mode (Real Estate)

Total

Total Balance

$

Total Installment

$

Percentage of income investing

Employer Match

Desired coverage amount ($)

Risk Tolerance

Conservative Moderate Aggressive

Financial Institution Name

Address

Preferred initial draft date

Subsequent draft date (1st-28th)

Total Monthly Expenses (All Bills--Food, Gas, Electric etc…)

AND / OR

Monthly Discretionary Income (left after Bills are paid)

CARE CIRCLE

Church Name:

Pastor:

Phone:

Address

State

Zip Code

Funeral Home

Director:

Phone:

Address

State

Zip Code

PAYMENT METHOD

Name on Card

Credit Card #

Card Holder Address

Exp. Date

Zip Code

CVV

ALTERNATE PAYMENT METHOD

Bank Name

Routing #

ACCT #

CLIENT SIGNATURE(S)

I hereby attest that the information on this Client Data Form has been provided by me and to the best
of my knowledge is accurate. I further understand that the information provided will be used with your
retirement software to create my retirement analysis. I understand fixed-only licensed insurance agents
may not suggest the sale of an insurance product based upon the sale or liquidation of securities
products. Proper registered registrations are required for such recommendations and sales. The information gathered with this form will be used for the sole purpose of helping create a financial strategy for your retirement. The financial professional providing the analysis does not provide tax or legal advice. Prior to making any financial decisions consumers should obtain tax or legal advice from a qualifying professional.

Client:

Date:

Client:

Date:

Agent:

Date:

For us to do our best job for you, please, upload the following information to our secure portal:
● MOST RECENT FEDERAL & STATE TAX RETURNS
● MOST RECENT PAY STUBS
● CURRENT INCOME
● FINANCIAL STATEMENT
● ESTATE DOCUMENTS
● CURRENT STATEMENTS
● WILLS AND TRUSTS
● BANK, MUTUAL FUND, BROKERAGE, 401(K), INSURANCE POLICIES , ETC.

*Please email the following documents to our secure corporate email address at support@rmafinancialgroup.com

Please Upload Documents as a PDF only

REFERRAL PROGRAM

Thank you for referring me to people you know 0-90 years old that are willing to meet me for a few minutes and complete a financial discovery like you did. Our team can help people no matter if they have insurance or not. You will receive $25 for everyone who works with me. In fact, it works best when you tell them who I am and I will be contacting them ahead of time.

ADVISOR'S NAME

PHONE

Referral Name

Referral Name 2

Referral Name 3

Referral Name 4

Referral Phone

Referral Phone 2

Referral Phone 3

Referral Phone 4

Referral Relationship

Referral Relationship 2

Referral Relationship 3

Referral Relationship 4

Referral Address

Referral Address 2

Referral Address 3

Referral Address 4

B.E.S.T (BUSINESS & EMPLOYEES SAVING TAXES) PLAN

Do you own or run a business?

Yes No

+1 888-504-5558

support@rmafinancialgroup.com

CLIENT PROFILE

Client

Significant Other

Emergency Contacts

Contact Person 1

Contact Person 2

Employment

Client

Significant Other

About Us

Quick Links

Our Service

Free Estimate

Call Us: +1 888-504-5558