Paycheck Protection™ Strategy Intake Confidential questionnaire used to evaluate income protection strategies 1. Contact Information Full Name Email Phone City State 2. Personal Information Date of Birth Gender Male Female Height Weight Tobacco Use No Yes 3. Occupation Information Occupation / Job Title Employer Name Job Duties Years in Current Occupation Years with Employer Business Owner No Yes Ownership Percentage (if owner) 4. Income Information Annual Base Income Annual Bonus / Commission / K1 Total Estimated Annual Income Estimated Annual Income Increase % Estimated Tax Bracket % Estimated Retirement Age 5. Existing Disability Coverage Employer Long Term Disability Plan? No Yes Percent of Income Covered Monthly Maximum Benefit Waiting / Elimination Period Benefit Period Employer Paid or Employee Paid Employer Employee 6. Existing Individual Income Protection Do you currently have individual coverage? No Yes Monthly Benefit Benefit Period Elimination Period COLA Rider No Yes Annual Premium 7. Major Assets (Optional) Primary Home Value Primary Vehicle Value Second Home / Cabin Value Other Major Assets 8. Health Information Back or Neck Issues No Yes Diabetes No Yes Heart Issues No Yes Blood Pressure Issues No Yes Cancer or Tumors No Yes Anxiety / Depression No Yes Drug or Alcohol Issues No Yes Current Medications Additional Health Notes 9. Income Protection Goals Monthly Income You Want Protected Preferred Waiting Period 30 Days 60 Days 90 Days 180 Days Preferred Benefit Duration 5 Years 10 Years To Age 65 To Age 67 Primary Concern If Income Stops Submit Paycheck Protection Intake This questionnaire is used to evaluate potential income protection strategies. Submitting this form does not guarantee eligibility or approval for coverage. Results depend on underwriting, eligibility, and plan design.
