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Client Questionnaire
Step
1
of
7
- Client Details
0%
Client
Title
Mr
Mrs
Miss
Ms
Dr
Given Names
*
Surname
*
Date of Birth
*
DD slash MM slash YYYY
Smoker Status
Non-smoker
Smoker
Do you have a partner?
Yes
Partner
Partner's Title
Mr
Mrs
Miss
Ms
Dr
Partner's Given Names
*
Partner's Surname
Partner's Date of Birth
*
DD slash MM slash YYYY
Partner's Smoker Status
Non-smoker
Smoker
Contact Details
Residential Address
*
Postal Address
(if differs from Residential Address)
Phone (client)
*
Phone (partner)
Email (client)
Email (partner)
Children
Do you have any children?
Yes
No
What are their names and ages?
Name
Age
Employment Details (client)
Occupation
Occupation Status
Full Time
Part Time
Self Employed
Home Duties
Employer Name
Expected Income ($)
Any expected changes?
Employment Details (partner)
Occupation
Occupation Status
Full Time
Part Time
Self Employed
Home Duties
Employer Name
Expected Income ($)
Any expected changes?
Other Details (client)
Estimated Living Costs ($)
Do you have a Will?
Yes
No
Do you have Private health insurance?
Yes
No
Other Details (partner)
Estimated Living Costs per annum ($)
Do you have a Will?
Yes
No
Do you have Private health insurance?
Yes
No
Assets
List your assets and current market value
Description
Value ($)
Liabilities
List Your Liabilities and current amount owing
(Please add details of any loans, credit card debt or other debts in the sections below)
Description
Amount ($)
Superannuation & Superannuation Pensions
Super fund / Pension fund
Estimated Balance ($)
Owner
Personal Insurance Details
Personal Insurance Details
Insert Type (Life, TPD, Trauma, Income Protection), Sum Insured and Insurer
Type
Sum Insured ($)
Insurer
Financial Concerns
What keeps you awake at night?
eg. Debt, job security, providing for family, will I have enough to retire?
Final Questions (client)
The following Four (4) questions ask you to rank your response on a scale whereby 1 is very low and 10 is very high;
On a scale between 1 (very low complexity) to 10 (very high complexity) – how complex do you think are your financial circumstances?
1 - very low complexity
2
3
4
5
6
7
8
9
10 - very high complexity
On a scale between 1 (no concern) to 10 (very concerned) – How concerned are you about reaching your financial goals?
1 - no concern
2
3
4
5
6
7
8
9
10 - very concerned
On a scale between 1 (not committed) to 10 (very committed) – How committed are you to making the necessary changes in your life to achieve your financial goals?
1 - not committed
2
3
4
5
6
7
8
9
10 - very committed
On a scale between 1 (no importance) to 10 (very important) – how important to you is a long term relationship with a financial planner that will help you achieve all of your financial goals?
1 - no importance
2
3
4
5
6
7
8
9
10 - very important
Final Questions (partner)
The following Four (4) questions ask you to rank your response on a scale whereby 1 is very low and 10 is very high;
On a scale between 1 (very low complexity) to 10 (very high complexity) – how complex do you think are your financial circumstances?
1 - very low complexity
2
3
4
5
6
7
8
9
10 - very high complexity
On a scale between 1 (no concern) to 10 (very concerned) – How concerned are you about reaching your financial goals?
1 - no concern
2
3
4
5
6
7
8
9
10 - very concerned
On a scale between 1 (not committed) to 10 (very committed) – How committed are you to making the necessary changes in your life to achieve your financial goals?
1 - not committed
2
3
4
5
6
7
8
9
10 - very committed
On a scale between 1 (no importance) to 10 (very important) – how important to you is a long term relationship with a financial planner that will help you achieve all of your financial goals?
1 - no importance
2
3
4
5
6
7
8
9
10 - very important
