Client Information
Fields marked * are required before continuing.
Primary Client
Spouse / Partner
Income & Monthly Expenses
Enter current or projected monthly amounts. Leave blank if not applicable.
Income Sources
| Source | Monthly $ | Client / Spouse | Notes / Start–End Year |
|---|---|---|---|
| Employment / Self-Employment | |||
| Social Security — Client | |||
| Social Security — Spouse | |||
| Pension / Defined Benefit | |||
| Required Minimum Distributions | |||
| Rental / Real Estate | |||
| Annuity Income (existing) | |||
| Other Income |
Monthly Household Expenses
| Expense Category | Monthly $ | Notes |
|---|---|---|
| Housing (mortgage / rent / HOA) | ||
| Utilities & Phone | ||
| Food & Groceries | ||
| Transportation (car payments, insurance, gasoline, and repair & maintenance) | ||
| Healthcare / Out-of-Pocket | ||
| Insurance Premiums (current) | ||
| Entertainment & Travel | ||
| Debt Payments | ||
| Other |
Assets & Debt
Approximate values are fine. Include all accounts held by either spouse.
Liquid & Investment Assets
| Asset Type | Approx. Value $ | Owner | Institution / Notes |
|---|---|---|---|
| Checking Account(s) | |||
| Savings / Money Market | |||
| CDs / Treasury Bills | |||
| Taxable Brokerage / Investment | |||
| Real Estate — Primary Home | |||
| Real Estate — Investment / Rental | |||
| Business Interests / Other |
Retirement Accounts
| Account Type | Balance $ | Owner | Institution |
|---|---|---|---|
| Traditional IRA | |||
| Roth IRA | |||
| 401(k) / 403(b) — Current Employer | |||
| 401(k) / 403(b) — Former Employer | |||
| SEP-IRA / SIMPLE IRA | |||
| Pension / Cash Balance Plan | |||
| Deferred Compensation | |||
| Other |
Outstanding Debt
| Debt Type | Balance $ | Mo. Payment $ | Rate % | Notes |
|---|---|---|---|---|
| Mortgage | ||||
| Home Equity / HELOC | ||||
| Auto Loan(s) | ||||
| Credit Cards | ||||
| Student Loans | ||||
| Other |
Current Insurance Coverage
List all current policies. Leave blank if you don't have that coverage.
Coverage Inventory
| Coverage Type | Company | Mo. Premium $ | Death Benefit / Benefit | Notes / Owner |
|---|---|---|---|---|
| Life Insurance — Term | ||||
| Life Insurance — Permanent (WL/UL/IUL) | ||||
| Annuity (existing) | ||||
| Long-Term Care Insurance | ||||
| Medicare Supplement (Medigap) | ||||
| Medicare Advantage Plan | ||||
| Employer / Group Health Insurance | ||||
| Dental / Vision | ||||
| Hospital Indemnity | ||||
| Other Supplemental Coverage |
Retirement Goals & Priorities
Help us understand what matters most. This shapes every recommendation we make.
What are your top priorities?
Check all that apply:
Authorization: By submitting this form, I authorize PremierCare Retirement Solutions to use the information provided solely for retirement planning purposes. I understand this does not constitute a binding agreement or product application.
Your information is confidential and used solely for retirement planning. PremierCare Retirement Solutions.
Thank you!
Your Retirement Financial Profile has been submitted to PremierCare Retirement Solutions.
We'll review your information and be in touch shortly to discuss your personalized retirement plan.