10WaysPre-App

Pre-Application for 10 Ways Affluent Retirees Overcome Concerns about Extended Care while Protecting Your Wealth AND Controlling Your CARE...IF You need care...Strategy Session!

Please complete and click submit when you've completed the Application...

Please complete this information as quickly as you can before our scheduled meeting. Having this information before our Strategy Session will mean we can spend more time on finding potential solutions instead of gathering information.

* Indicates required field

Name *

First

Last

Email *

Mobile Phone Number *

Primary Date of Birth *

Ideal Retirement Date *

If Married, complete Spousal information...otherwise skip this section.

Name *

First

Last

Spousal Email *

Spouse's Phone Number *

Spouse Date of Birth *

Spouse's Ideal Retirement Date *

Please list your current retirement assets, including Type, Estimated Balance, Amount of Any Monthly Contributions.

Account Name *

Account Type *

Estimated Balance *

Monthly Contribution (if any) *

Account Name *

Account Type *

Estimated Balance *

Monthly Contribution (If any) *

Account Name *

Account Type *

Estimated Balance *

Monthly Contributions (If any) *

Account Name *

Account Type *

Estimate Balance *

Monthly Contributions (If any) *

Account Name *

Account Type *

Estimated Balance *

Monthly Contribution (If any) *

Account Name *

Account Type *

Estimated Balance *

Monthly Contribution (If any) *

Account Name *

Account Type *

Estimated Balance *

Monthly Contribution (If any) *

Account Name *

Account Type *

Estimated Balance *

Monthly Contribution (If any) *

Account Name *

Account Type *

Estimated Balance *

Monthly Contribution (If any) *

Account Name *

Account Type *

Estimated Balance *

Monthly Contribution (If any) *

Home and Mortgage Information (Please enter your Principal & Interest Payment without Taxes & Insurance)

Company Name *

Mortgage Balance *

Months Remaining *

Interest Rate *

Principal & Interest *

Company Name *

Balance *

Months Remaining *

Rate *

Principal & Interest *

Auto Loans

Company Name *

Balance *

Months Remaining *

Interest Rate *

Payment *

Company Name *

Balance *

Months Remaining *

Interest Rate *

Payment *

Other Debt: Including Personal Loans, Credit Cards, etc...

Company Name *

Balance *

Rate *

Minimum Payment *

Company Name *

Balance *

Rate *

Minimum Payment *

Company Name *

Balance *

Rate *

Minimum Payment *

Company Name *

Balance *

Rate *

Minimum Payment *

Company Name *

Balance *

Rate *

Minimum Payment *

Company Name *

Balance *

Rate *

Minimum Payment *

Please enter your Current Income

Who's Income *

Monthly Amount *

Type of Income *

Who's Income *

Monthly Amount *

Type of Income *

Who's Income *

Monthly Amount *

Type of Income *

Who's Income *

Monthly Amount *

Type of Income *

Who's Income *

Monthly Amount *

Type of Income *

Social Security Info..(If not already listed above) If you don't know your Primary Insurance Amount...We can estimate it based on Annual Salary.

Primary-PIA Amount *

Spouse-PIA Amount *

Pension Income...(If not already listed above) If you're expecting a Pension please enter your Estimated Annual Amount.

Primary Estimated Annual Pension *

Spouse Estimated Annual Pension *

Please enter your concerns surrounding the possibility of needing Extended Care?

Concerns *

Do you currently have any type of Insurance to help pay for any needed Extended Care? *

If You Needed Extended Care What Account Would You Withdraw Money to Pay for It? *

If You Require Extended Care...Where Do You Want to Receive It? *

Submit