Brewer Capital Client Questionnaire

PERSONAL INFORMATION


SPOUSE PROFILE

(Spousal information IS required for married individuals, even if opening a single name account)


EMERGENCY INFORMATION


CORPORATION INFORMATION


FINANCIAL PROFILE

(If Possible, please use approximate dollar values. Otherwise use letter codes found below)









CURRENT INSURANCE COVERAGE

CARRIER

POLICY #

AMOUNT

DATE ISSUED

PREMIUM

Health

Disability

Life

Long Term Care

Auto

Homeowners or Renters

Personal Umbrella

Business Owner

Business Liability

Other (Specify)


FINANCIAL ADVISOR 1


Accountant


Manager/Executive Assistant


Attorney


Health Insurance Agent


P and C Insurance Agent


Investment Banker


Life Insurance Agent


Lender/Mortgage Broker