Benefits Consultants
Tim B. Piatchek, LUTCF, LC

Serving the Ozarks and

Southwest Missouri

since 1968!

Call us locally at 417-877-1567 or Toll-Free at 866-716-4555
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MEET TIM!

Individual Health Plan

Group Health Plan

Term Life Insurance

IRA - Annuities - 401K Rollover - Retirement Planning

The quote you are requesting requires that you complete the following survey as completely and accurately as possible. Once submitted, your information is e-mailed to our office and we will process your request. This information is kept confidential and used for quote purposes only.

*Required fields marked in yellow

Contact Information
*Name:
*Address:
*City:	State: Zip:
*Phone:	Work:
	Home:
	Fax:
Email Address:

Personal Information
Date of Birth:	//
Gender:	Male Female
Retired?:	Yes No
Current/Former Occupation:
Spouse's Date of Birth:	//
Spouse Retired?:	Yes No
Spouse's Current/Former Occupation:
Number of Children:
Number of Children between the ages 0-4:
Number of Children between the ages 5-9:
Number of Children between the ages 10-14:
Number of Children between the ages 15-19:
Number of Children between over 19:
Do you have a Will?	Yes No
Do you have a Power of Attorney Assets?	Yes No
Do you have a Power of Attorney Health?	Yes No
Do you want Children's Names on your accounts?	Yes No
Do you have a Living Trust?	Yes No
Do you have an Umbrella Liability Insurance?	Yes No
Do you have a Long Term Care Insurance?	Yes No
Do you have a Living Will?	Yes No

Current Investments

Credit Union/Bank Accounts?
Yes No

Mutual Funds/Stocks/Bonds?
Yes No

Brokerage Accounts? Yes No

Retirement Accounts from Work?
Yes No

C.D.'s?
Yes No

Treasury Bills/Savings Bonds?
Yes No

Annuities?
Yes No

IRA/401K/Keoghs/TSA?
Yes No

Insurance (Life, Long Term Care)
Yes No

Promissory Notes/Contract for Deed:
Yes No

Other Assets: Yes No

Do you live off the interest your savings/investment dollars earn?: Yes No

Real Estate - Home Value:

Real Estate - Automobiles and Personal Property:

Real Estate - Other:

Business Interests:

Liabilities/Debt
Liability/Debt Type:	Amt Owed:
Liability/Debt Type:	Amt Owed:
Liability/Debt Type:	Amt Owed:
Liability/Debt Type:	Amt Owed:

Monthly Income
	Self Amount Spouse Amount
Social Security:
Pension:
Wages:
Other Income:

Annual Living Expenses
Are you satisfied with your current monthly income?	Yes No
Do you anticipate any changes in your annual income?	Yes No
Are you planning any major lifestyle changes? (selling a home, moving, purchasing a home,etc.)	Yes No
Do you foresee any large purchases in the next 2-5 years?	Yes No
If yes, please explain:

Personal Preferences Please select the level of importance for each statement.
Pay less income tax:
Reduce or eliminate Estate Taxes and/or Capital Gains Taxes:
Increase my monthly income:
Avoid the probate process:
Protect my assets and family from catastrophic long term care costs:
Ensure that my assets are protected from stock market losses:
Increase my returns on savings and retirement funds:

Additional Considerations/Requests

Please add any comments/questions not covered above.

Please click on the "Send Request" button to send us your quote request.

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Contact Information

Personal Information

Current Investments

Liabilities/Debt

Monthly Income

Annual Living Expenses

Personal Preferences

Additional Considerations/Requests