CLIENT INFORMATION:
Your Name:
Your Date of Birth:
Spouse Name:
Spouse Date of Birth:
Your Home Phone:
Your Cell Phone:
Spouse Home Phone:
Spouse Cell Phone:
Street Address:
City:
State:
Zip:
List Children's Names and Ages:
HOW WILL YOU USE YOUR BANKING POLICY - Check all that Apply:
DEBTS to CONVERT or TRANSFER INTO YOUR BANKING POLICY:
Cars/Recreational Vehicles:
Description
Current Balance
Interest Rate
Payment Amount
Credit Cards/Loans/Mortgages:
EDUCATIONAL FUNDING:
Educational Savings Plans 529 - UTMA - UGMA - Educational IRA
(Average college cost projected to be $250,000 per student.)
Current Monthly Educational Savings: $
INVESTMENTS and RETIREMENT SAVINGS - CDs, Annuities, 401K, IRA, Stocks, Bonds
Type
Qualified Yes or No?
Monthly Contribution
Market Value
Rate/Return
YOUR CURRENT INSURANCE COVERAGE
Type - Term,Whole Life,UL
Monthly Premium
Cash Value
Notes:
How much do you currently save monthly on average?
Other: Input your average monthly savings. $
FUNDING YOUR MPG BANKING POLICY
(Minimum is the fixed contribution. All additional funds over and above the minimum are available as liquid cash for banking.)
Minimum: $
Average: $
Maximum: $
WHO SENT YOU TO THIS SITE?
(Please provide us with the name of the MPG Agent who asked you to fill in this form. Thank You)
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