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ENROLMENT FORM

Please complete the following form and send it to us to take advantage of all of the valuable benefits that come with membership:

Note: All information will be kept confidential and not shared with any other company.

*Items marked with an asterisk are mandatory fields.

Names & Age: Individual 1 Individual 2
First Name, Middle Initial *
Last Name *
Birth Date
Gender (Male/Female)
U. S. Citizenship

Marital Status:  (check one)   Single    Married

Home Address:
Address *
City

 * State  *  Zip  *
Phone Number *
Phone Number 2
Fax Number
Email Address *

Financial Objectives

<<Low                       High>> 

Reducing income taxes

               

Protection from inflation

               

Maximum investment growth potential

               

Current spendable income from assets

               

Liquidity (convert assets to cash)

               

Note: Place a mark in the circle closely representing the financial objective for each of the above statements.

Financial Concerns – please check all that apply*

Investment Asset Allocation

Retirement Planning

Education Funding

Life Insurance Needs Analysis

Disability Insurance Needs Analysis

Long Term Care Insurance Needs Analysis

Estate Planning

Other

Retirement Analysis

What are your plans for retirement

Can you describe your planned lifestyle in retirement?

How does this compare to your current lifestyle?

How much are you systematically investing outside of your retirement plans?

Do you plan to sale any assets to fund your retirement?

Do you anticipate any additional income needs during retirement?

Do you anticipate working part-time in retirement?

Is there any anticipated windfall of assets or income that will be used for retirement?

 

Individual 1

Individual 1
Retirement Age

Estate Planning

What provisions have you made for your estate?

  Individual 1 Individual 2
Last Will & Testament
Marital Trust provision
QTIP Trust provision
Credit Shelter
Bypass Trust provision
Family/Minor Trust provision
Executor provision
Trustee provision
Specific/Direct Bequest
Charitable Bequest
Living Trust
Irrevocable
Life Insurance Trust
Power of Attorney
Health Care Power of Attorney
Annual Gifting
Lifetime Taxable Gifts
Lifetime Exemption utilized

What type of legacy would you like to leave upon your death? 

Are you interested in strategies that minimize death taxes?

Do you prefer simple or complex solutions?

How much control over your assets are you willing to give up?

Are you charitably inclined?

Notes:

 
* Member FINRA, SIPC and Registered Investment Adviser.

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Premier Capital Management, Inc.   ::   (818) 888-4646    ::    California Insurance License No: OD78394