Congratulations on taking this first step to eliminate financial risks and build company value! Please, provide the information requested below and then click SUBMIT. Or, print the form, fill in the data and fax same to us at (888) 655-6415. If you have questions, please call (888) 950-8376, or write to We will contact you as soon as we receive your information to start the evaluation process. 

A) Company Data
Name of Business:
Person to call at company regarding this form:
Nature of Business:
Type of Business: Sole ProprietorshipPartnership"C" Corporation"S" CorporationPersonal Service Corp.Limited Liability CompanyOther
Calendar of Fiscal Year:
Business Owner(s) How Many?:
What % of Ownership Each Has:
Regarding Corporation
Total Number of Shares Outstanding:
Corporate Tax Bracket:
State of Incorporation:
Date of Incorporation:
Are Owners Still Active in Business?:
What is the approximate net worth of the business?:
Would you consider your business a good investment for your family if you were not active in it?:
Do you have a child or other relative now active in the business or one who intends to be active?: YesNo
Do your associates have children or other relatives now active in the business or any who intend to be active?: YesNo
Does the business have outstanding debts?: YesNo
Have you assumed personal liability for any business obligation (note or lease)?: YesNo
If yes, Type:

Average annual earnings of business:
Last Three Years:
Last Five Years:
Business Attorney:

Business Accountant:

B) Buy-Sell Planning
Is there a Buy-Sell Agreement in place?: YesNo
C) Key Person/Executive Benefits
In addition to yourself, do you have any other Key People in your business?: YesNo
If yes, How Many?:
Does the business own life insurance on these people?:

Do you provide Split-Dollar insurance for anyone in your business?: YesNo
Are there Deferred Compensation plans in place now?: YesNo
If NO, are there any Key Employees whom you would like to tie to the Company by providing them with retirement income and/or death benefits that they would lose if they left your Company?: YesNo
Are there Executive Bonus Plans in place?: YesNo
If NO, would you be interested in a way of providing life insurance
for yourself and/or any key people, with the premiums paid for and deducted by the Company?:
D) Qualified Sick Pay Plan
Does the Company have a long-term disability plan?: YesNo
Does the Company have individual disability policies for Key Personnel?: YesNo
E) Qualified Retirement Plans
Is there one or more qualified retirement plan in place?: YesNo
If YES, which type(s)?: Defined BenefitMoney PurchaseProfit Sharing401(k)SIMPLE IRASEP412(i)
F) Medical Benefits
Do you have a Medical Plan in place?: YesNo
Do you have a Dental Plan in place?: YesNo
Do you have a Vision Plan in place?: YesNo
If NO, to any of the above, would you like to consider implementing one or more of the above plans?: YesNo
G) Group Term Life Insurance
Does your Company currently have a Group Term Life Insurance Plan in place?: YesNo
If YES Are the costs too high?:
Would you like to provide additional coverage for Key Personnel?

If NO, would you like to evaluate implementing a Group Term Life Insurance plan?: YesNo
H) Business Overhead Expense Insurance
Do you currently have Business Overhead Expense Insurance in Place?: YesNo
If NO, would you like to evaluate the benefits of such a plan?: YesNo