New Client Information Form Please enable JavaScript in your browser to complete this form.Who are you working with? *This will ensure proper routing of your form after you complete it.Choose your agentLuke TatumJeremiah MartinAaron DowdellCorey SinzRob BraytonIvan CangasThis is not an application for life insurance or any other financial product. This form is intended to provide more insight into your personal information and family finances. If you decide to apply for a product, this information may be used (with your consent) for that purpose as well. Please do not fill this form out unless you have spoken with someone at Perfect Spiral Capital. It will take some time to complete. Make sure you have at least 30 minutes (it could take more or less time, depending on the complexity of your situation.) It may be helpful to look ahead and gather the appropriate documentation before beginning to fill the form out. Policy Owner: Personal Information In the Policy Owner sections we will deal with the proposed owner of the policy. This can be the same person as the insured, or it can be a different person. Please ask if you have any questions! Legal Name* Enter your name as it appears on your Driver's License. First Name *First NameLast Name *Last NameNicknameNicknameDate of Birth *Enter the date of birth for the owner of the policySex *Male or Female?MaleFemaleNicotine Use *Have you ever consumed nicotine products in any form? (Cigarettes, cigars, vaporized liquid, gum, etc.)?NoYes If so, what was used and approximately when was the most recent use? Cannabis Use *Have you ever consumed cannabis products in any form? (CBD creams or oils, marijuana, etc.)?NoYesIf so, what was used and approximately when was the most recent use? Address *Enter your address as it appears on your Driver's License. Address Line 1Address Line 2CityState / Province / RegionPostal Code--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPhone *Please enter your best contact number. Email *Please enter your preferred email for correspondence related to your life insurance policy. Policy Owner: Past FinancesDo you currently work for income? *NoYesEarned Income *Enter the gross earned income (salary, wages, commissions, and bonuses before taxes and withholding) that you received in the past 12 months. An exact dollar amount is not required, but this should be a reasonable representation of your income. Occupations (Earned Income Sources) *How did you earn this income? Please list all income sources and a brief description of each. Do you currently receive income from any source other than work? *Examples include dividends form stocks, interest payments, Social Security income, withdrawals from retirement accounts, rental property income, etc.)NoYesUnearned Income *Enter the gross unearned income (dividends, interest, Social Security income, withdrawals from retirement accounts, rental property income, etc. before taxes and withholding) that you received in the past 12 months. An exact dollar amount is not required, but this should be a reasonable representation of your income. Unearned Income Sources *Please briefly describe any sources of Unearned Income. If none, please type “N/A.” Do you expect your income to change in the next 12 months? *NoYesPlease briefly describe your expected income changes. *Net Worth: Policy Owner AssetsCash *Enter total cash holdings. This should include physical cash as well as money held in bank accounts. Stocks and Bonds *Enter total value of current stock and bond holdings. Real Estate *Enter the current market value for all real estate holdings. Other Assets *Enter any other assets not listed above. Examples could include gold, silver, your ownership stake in a business, the value of vehicles, the value of rare collectables, etc. Other Asset Sources *Please briefly describe the sources of any Other Assets. If none, please type “N/A.” Liabilities Do you currently have any mortgages? *NoYesMortgages *What is the current balance on your mortgages?Mortgage Information *Please enter additional details for each mortgage. What was the original length of each mortgage? How many years are left on each? What is the current value of each property? What is your monthly payment for each? Do you currently have any other debts? *Car loans, credit cards, etc.NoYesOther Debts *What is the current balance of your other outstanding debts? (Car loan, student loan, credit card, home improvement loan, etc.) Other Debts Information *Please enter additional details for each debt. What was the original length of each repayment? How many years are left on each? What is your monthly payment for each? Bankruptcy *Have you filed for bankruptcy within the last seven years?NoYesBankruptcy Discharge Date *If you have filed for bankruptcy in the last seven years, select the discharge date below. Current Life Insurance Coverage Do you currently have life insurance on your own life? *(From any source. Personally owned, paid through payroll deduction at work, offered by a credit union, etc.) NoYesPolicy Information *For each policy where you are the insured person, please list: Life insurance company Death benefit Type (Term, Whole, Universal, etc.) Date of Issue If none, please type “N/A.” Policy Owner’s Partner: Personal Information In the Policy Owner’s Partner sections, we will complete the same information for your fiancée or spouse, if applicable.Are you married or engaged to be married? *NoYesPartner's Legal Name* Enter your name as it appears on your Driver's License. First Name *Last Name *NicknamePartner’s Date of Birth *Enter the date of birth for the partner of the owner of the policySex *MaleFemale Partner’s Nicotine Use *Has your partner ever consumed nicotine products in any form? (Cigarettes, cigars, vaporized liquid, gum, etc.)?NoYes If so, what was used and approximately when was the most recent use? *Partner’s Cannabis Use *Has your partner ever consumed cannabis products in any form? (CBD creams or oils, marijuana, etc.)? NoYesIf so, what was used and approximately when was the most recent use? *Is your partner's street address the same as your own? *YesNoPartner’s Address *Enter your partner’s address as it appears on his or her Driver's License. Address Line 1Address Line 2CityState / Province / RegionPostal Code--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPartner’s Phone *Please enter your partner’s best contact number. Partner’s Email Address *Please enter your partner’s preferred email for correspondence related to your life insurance policy. Policy Owner’s Partner: Past FinancesDoes your partner currently work for income? *NoYesEarned Income *Enter the gross earned income (salary, wages, commissions, and bonuses before taxes and withholding) that your partner received in the past 12 months. An exact dollar amount is not required, but this should be a reasonable representation of your partner’s income. Occupations (Earned Income Sources) *How did your partner earn this income? Please list all income sources and a brief description of each. Does your partner currently receive income from any source other than work? *Examples include dividends form stocks, interest payments, Social Security income, withdrawals from retirement accounts, rental property income, etc.)NoYesUnearned Income *Enter the gross unearned income (dividends, interest, Social Security income, withdrawals from retirement accounts, rental property income, etc. before taxes and withholding) that your partner received in the past 12 months. An exact dollar amount is not required, but this should be a reasonable representation of your partner’s income. Unearned Income Sources *Please briefly describe any sources of Unearned Income.Does your partner expect his or her income to change in the next 12 months? *NoYesPlease briefly describe the expected changes to your partner's income. *Partner’s Current Life Insurance Coverage Is your partner currently insured? * (From any source. Personally owned, paid through payroll deduction at work, offered by a credit union, etc.) NoYesPolicy Information *For each policy where you are the insured person, please list: Life insurance company Death benefit Type (Term, Whole, Universal, etc.) Date of Issue If none, please type “N/A.” Do you have any children?NoYesChildren Information *List the full legal name and date of birth for each of your children. If none, enter "N/A.” Children Insured? *For each policy where your child is the insured person, please list: Life insurance company Death benefit Type (Term, Whole, Universal, etc.) Date of Issue If none, please type “N/A.” Do you have any grandchildren? *NoYesGrandchildren Information *List the full legal name and date of birth for each of your grandchildren. If none, enter "N/A.” Who is the proposed insured? *Please list the name(s) of any persons you may wish to insure.Underwriting Concerns *For the proposed insured(s), do you have any underwriting concerns other than tobacco and/or cannabis use? Weight, diabetes, high blood pressure, high cholesterol, hazardous occupations, and many other things may impact the risk class of a particular person. We can discuss possible impact on health rating during our next conversation.NoYesDesired Premium PaymentHow much total premium (base policy and Paid-Up Additions) do you want to pay per year, for all policies you want to apply for? This question is not required, but it is extremely helpful for our next conversation. Your answer can (and probably will) change as we continue to talk. Unless otherwise specified, we will split this budget roughly equally among the proposed insured(s) listed above.Submit