Full Name

Date of Birth

Address

Gender
FemaleMale

Cell Phone Number:

Can we text you? YesNo

Email Address:

Employment Status
UnemployedRetiredEmployed

Marital Status
MarriedSingleDivorced

Driver's License Information:
Driver's License Number:
State of Issue:
Expiration Date:

Financial Questions:

What is your annual household income?

What is your annual earned income?

What is your liquid net worth (amount in checking, savings, money market accounts)?

What are your monthly household living expenses (e.g. mortgage, utilities, insurance, food, loans)

Do you currently have a retirement plan? YesNo

If yes, please list all retirement plans in the household, including ownership, name of the investment company, type of retirement account (403b, 401k, IRA, Roth IRA, etc.) and account balance:

Do you have other investments? YesNo

If yes, please list all other investments in the household, including ownership, name of the investment company, type of investment vehicle (CD, mutual funds, stocks, 529 plan, annuity, etc.) and approximate balance:

Do you own your home? YesNo

If applicable, what is your approximate mortgage balance?

Do you own a secondary residence or investment property? YesNo

If yes, what is the address and do you rent out the property?

Do you have any dependents? YesNo

If yes, What is their name, relationship and date of birth:

Do you have life insurance? YesNo
If yes, please provide name of insurance company, death benefit amount, and type of policy (e.g. 20 year term, whole life, or indexed universal life)? (Leave blank if unknown)

Retirement Risk Profile Questions:

How many years from now do you expect to start spending the money you’re investing? More Than 30 years20-30 years10-20 years5-10 yearsLess than 5 years

Once you begin withdrawing funds from this investment, how long do you expect the money to last? I plan to take a lump sum distributionLess than 2 years2 - 5 years6 - 10 years11 years or more

With your understanding that investing involves a tradeoff between risk and reward, what is your primary investment goal? I want to maximize the growth of my portfolio. I am willing to accept large and sometimes dramatic fluctuations in the value of my investments.The primary goal of my portfolio is growth. I am willing to accept some fluctuations in the value of my investments.I want my portfolio to be balanced, keeping risk to a minimum while trying to achieve slightly higher returns over time.I am very concerned with preserving the value of my portfolio. In order to minimize the chance of loss, I am willing to accept the lower long-term returns provided by conservative investments.

How comfortable are you with potential fluctuations in your portfolio? The example portfolio’s below show an hypothetical best-case gain %, and hypothetical worst-case loss % of five sample portfolios over a one-year period. For illustrative purposes only. Please choose the portfolio you would prefer. Portfolio 1: 10% gain to 15% lossPortfolio 2: 14% gain to 19% lossPortfolio 3: 21% gain to 27% lossPortfolio 4: 30% gain to 35% lossPortfolio 5: 33% gain to 38% loss

Historically, markets have experienced downturns and upswings. There have been several periods in history in which the value of the market has dropped more than 25% in a year. The most aggressive portfolios have seen even further declines. If the value of your portfolio fell from $100,000 to $75,000 (25%) in one year, how would you react assuming you still have 10 years until you begin withdrawals? I would sell all of my portfolio.I would sell some of my portfolio.I would do nothing.I would view this as an opportunity and potentially invest more in my portfolio or rebalance my existing portfolio.

I prefer low-risk investments even if their returns are lower than the inflation rate (the risk your money will buy fewer goods and services in the future because of rising prices). Strongly agreeAgreeNeutralDisagreeStrongly disagree

Do you give permission for your information to be shared with Larrow Insurance for follow-up? If so, please enter: "Yes, I consent."