Williams Insurance Agency, Inc.

 

"Your Safe Money Consultant"

 

20220 Coastal Hwy , Rehoboth DE 19971

Phone: 302 227 2501 . Fax: 302 227 3173

 

 

Client Information

Name:
Phone #:
E-mail:
Age or Date of Birth:
Amount: $
Qualified?
Where are the funds now?

MF     VA      CD      Fixed Annuity    

Other:         

Is there a market loss?   Y      N                  If Yes, how much 
Is there a surrender charge?   Y      N                  If Yes, how much 
Current Rate:  %
Are they using income?   Y      N                  If Yes, how much   $ /Mo
If using income, what type?
Do they need an income stream?
Required Minimum Distribution or more? 
Goals for the money.   

Beneficiaries (if other than spouse)

& how do they want distribution?
Total Net Worth: $  
Percent of Net Worth at Risk:    
Notes & special considerations:  

 

Please print & then fax this form to Bud Clark   or simply click the "Submit Form" button above to have the information emailed to Bud
Copyright © 2009[Williams Insurance Agency, Inc.]
All rights reserved.
Revised: 12/23/10