Book Legacy Coaching | Kingdom Finance

"Legacy is not only about what's left tomorrow when you're gone.

It's also what you give, create, impact, and contribute today while you're here."

This form is PII Encrypted to protect your personal identifiers and information. PII (Personally Identifiable Information) includes items such as full name, address, email address, social security numbers, phone number, etc. Wix guidelines require all PII data to be stored encrypted by the application that handles the data.

Client Information:

Full Name (First and Last):

Date of Birth:

SSN:

Height and Weight

Biological Sex:

Place of birth (City, State)

Martial Status:

Address:

Years at Address:

Phone

U.S. Citizen

If no, specify Country of citizenship and type of Visa:

Driver's License

Issue State:

Expiration Date:

Tobacco/Marijuana use within past 5 years?

If yes, please briefly describe frequency, type, date of last use:

Employer Information:

Employer:

Years at Employer:

Employer Address:

Job Title and Duties:

Employer Phone:

Gross Income Current Year

Gross Income Previous Year:

Net Worth

Beneficiaries (Primary and Contingent):

Primary Beneficiary (List name, SSN, DOB):

Contingent Beneficiary (List name, SSN, DOB):

Premium Payment Information:

Bank Name:

Account Type:

Account Number:

Routing Number:

Medical History/Primary Physician:

Medical Condition(s) within the last 10 years including date of diagnosis:

Medications, if any:

Physician Full Name:

Physician Phone:

Physician Address:

Date last seen:

Reason and result (if any):

You're Almost Done!

Are you familiar with Life Insurance and Annuities? If so, briefly explain your understanding of each.

Do you currently hold any Life Insurance policies or Annuities?

Yes, one of each

Yes, only Life Insurance

Yes, only an Annuity

None at all

What is your preferred method of communication?

Call or Text

How did you hear about us? If a friend referred you, please let us know so we can thank them!