Instructions





This Intake Form is quick and easy to fill out, taking on average only 8 minutes. The more accurate your information is, it will help your Agent/Analyst, if you estimate or "guess" about some of the figures, they can always be updated by your Agent later.

If at anytime you can't complete the entire form, you simply need to click the "Finish Later" button at the bottom, this will save your data in a cookie on THIS computer and send you an e-mail with the link back to this form. (Agents Note: no e-mail is sent if you click the "Finish Later" button). Thank you ahead of time for taking the time to fill this information in, this concept has changed thousands of lives by giving THEM full control of their Financial future and we look forward to seeing what it can do for you!

When you are finished, click the "Next" button until you get to the "Complete Intake Form" screen where there will be a BIG grey button saying "Send to my Coach (your Agent's full name)". Clicking that button will send an e-mail message to your Agent notifying them that you have competed the form and will close out this box.

Head of Household





Head of Household Information
(Names) First: Last:
City: State:
(Phones) Home: Work: Mobile:
E-Mail Address:
Date of Birth: e.g. 11/22/1988, 11-22-1971, or 11.22.63 Age:

Income Information
Monthly Income: Additional Income:

Existing Life Insurance
Policy Face Value:
Premiums: Monthly Amount: Annual Amount: Cash Values:

Spouse or Significant Other





Spouse Information
(Names) First: Last:
Date of Birth: Age:

Income Information
Monthly Income:

Existing Life Insurance
Policy Face Value:
Premiums Monthly Amount: Annual Amount: Cash Values:


Assets









Assets
Savings Monthly Contribution:
Stocks Monthly Contribution:
Mutual Funds Monthly Contribution:
Retirement Accts Monthly Contribution:
Qualified Plans Monthly Contribution:
Additional Assets:
Additional Assets:

Mortgages







Home Mortgage(s) - up to 2
Home and Property Value:



1st Mortgage:
Type: Current/Outstanding Balance:
Monthly Payment:
Interest Rate: %
Loan/Note Length: (years) * NOT years remaining
2nd Mortgage:
Type: Current/Outstanding Balance:
Monthly Payment:
Interest Rate: %
Loan Length: (years)

Credit Cards - up to 5





Credit Card 1:
Bank/Issuer: Type:
Balance owed: Minimum Payment: Actual Payment: Int. Rate: %
Credit Card 2:
Bank/Issuer: Type:
Balance owed: Minimum Payment: Actual Payment: Int. Rate: %
Credit Card 3:
Bank/Issuer: Type:
Balance owed: Minimum Payment: Actual Payment: Int. Rate: %
Credit Card 4:
Bank/Issuer: Type:
Balance owed: Minimum Payment: Actual Payment: Int. Rate: %
Credit Card 5:
Bank/Issuer: Type:
Balance owed: Minimum Payment: Actual Payment: Int. Rate: %

Vehicle Loans - up to 3





Vehicle Loan #1:
Make: Model: Year:
Balance owed: Mo. Payment: Int. Rate: % Loan Length: (in yrs)

Vehicle Loan #2:
Make: Model: Year:
Balance owed: Mo. Payment: Int. Rate: % Loan Length: (in yrs)

Vehicle Loan #3:
Make: Model: Year:
Balance owed: Mo. Payment: Int. Rate: % Loan Length: (in yrs)

Additional/Miscellaneous Debts





Additional Debts/Loans - up to 4
Type: Balance owed:
Monthly Payment: Interest Rate: % Length: (in yrs)
Type: Balance owed:
Monthly Payment: Interest Rate: % Length: (in yrs)
Type: Balance owed:
Monthly Payment: Interest Rate: % Length: (in yrs)
Type: Balance owed:
Monthly Payment: Interest Rate: % Length: (in yrs)
Comments/Notes/Explanations



Complete Intake Form





If you wish, you may use the "Next" and "Back" buttons below to browse through the input pages to review the data that was entered, or you may save the data entered so far and return later. NOTE: If your computer "privacy" setting automatically clears cookies at the end of a browser session, whatever you have entered will be lost! When all entry and review is completed, click the "Send to ..." button to record the final version of your data, which will notify your agent that the data is ready to be reviewed. NOTE: AAS has taken steps that are compliant with security standards for leading internet companies to ensure that your data is protected.


Your browser does not support CSS animations.