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Please fill out as much information below as possible so we can accurately assess your individual needs and determine what strategies may be right for you. Once you submit the form, one of our Client Relations Managers will contact you to walk you through our process.

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Please check all that apply:
  I am a financial advisor interested in being able to integrate QuadWealth strategies into the wealth management planning that I do for my clients.
  I am looking to integrate a specific QuadWealth strategy into my existing wealth management plan, or I am looking to get a second opinion on my overall, current wealth management plan and how I can improve it. This includes my current tax plan, estate plan, and investments that I am currently using for growth and/or income.

 In what area(s) are you most interested: (check all that apply) 
 Life Settlement Investments
 Investment Notes
 Real Estate Investments
 Annuity Investments
 Stock Market Investments
 Tax Planning Strategies
 Estate Planning Strategies
 Asset Protection Strategies


PERSONAL INFORMATION

First Name: 
Last Name: 
Date of Birth:

Marital Status:
Married
Divorced
Single

Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Email:
Preferred method of contact:
Email
Cell Phone
Home Phone
Work Phone
The best time to contact me is:
Morning
Afternoon
Evening

Employer:

Position/Title:
How Long:
Monthly Income:
401(k) Balance:
IRA Balance:
Stock Value:
Mutual Fund:
Annuity Balance:
Credit Rating:
Excellent
Fair
Poor

Have you ever had a bankruptcy?
Yes
No

Have you ever had a foreclosure?
Yes
No

Do you currently have any life insurance?
Yes
No

If your policy has any cash value, what is the amount?


SPOUSE INFORMATION

Full Name:
Date of Birth:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Email:
Employer:
Position/Title:
How Long:
Monthly Income:
401(k) Balance:
IRA Balance:
Stock Value:
Mutual Fund:
Annuity Balance:
Credit Rating:
Excellent
Fair
Poor

Have you ever had a bankruptcy?
Yes
No

Have you ever had a foreclosure?
Yes
No


PRIMARY RESIDENCE INFORMATION

Property Type:
Single Family Residence
Duplex
Condo
Manufactured Home

Year Purchased:
Purchase Price:
Current Value:;
1st Mortgage Holder:
Balance:
Monthly Payment:
Do you Escrow?
Taxes/year:
Insurance/year:
Rate (%):
Term (years):
Loan Type:
Fixed Rate
ARM
Balloon

2nd Mortgage Holder:
Balance:
Monthly Payment:
Do you Escrow?
Taxes/year:
Insurance/year:
Rate (%):
Term (years):
Loan Type:
Fixed Rate
ARM
Balloon

Comments:

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