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Last Name
Phone *
Email *
Subject:
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Welcome to the Financial Needs Analysis by LUFI

Enter your most accurate information into our secure software platform.

Thank you.

Your Contact Profile

Full Name *

Email *

Phone *

Today's Date *

Who is your agent? *

My Agent

Nelson Page
Anthony Lofton
Anthony Washington
Frank Northern
Robert Jackson
Tanisha Johnson
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How do you prefer to receive your results, updates, and communications regarding your financial progress?

Phone

Text

Email

Select all that apply

I agree to terms & conditions provided by the company LUFI. By providing my phone number and email, I agree to receive messages from the company LUFI powered by FFS.

Date of birth *

Address

Do you have a Spouse? *

Yes, Married / Partner
No, I'm single
Divorced
Fiancé
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List is empty.

Do you have any children? *

Choose One

Yes
No
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List is empty.

Your Spouse's Info

Spouse Full Name

Spouse Date of Birth

Spouse Email Address

Spouse Phone

Your Children's Info

How many children do you have?

What are their names, current age, and birthdays?

Details About You

Do you have a vaild driver's license? *

Yes

No

Suspended

Driver's License Number

DL State

Do you use any tobacco products? *

No
Yes, incluing Marijuana
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List is empty.

What is your current occupation / work status? *

Your Financial Goals?

Out of these 6 Step toward Reaching your Financial Goals which ones would make an impact for you the most?

Increase Cash Flow

Manage Debt

Long-Term Planning

Proper Protection

Emergency Fund

Additional Services - ie: Long-Term Care

What are your Top 3 Financial Goals that are most important to you?

Build Retirement Wealth
Buy A New Home
Finance College For Children
Pay Off Credit Cards
Alternate Income In Case Of Death Or Disability
Make A Major Purchase (car, boat, vacation)
Help Support Aging Parents
Build Savings For Unexpected Expenses
No elements found. Consider changing the search query.
List is empty.

Select All 3 That Apply

Any other Financial Goals that you didn't see listed?

Your Health

What is your Height? *

As accurate as possible

What is your Weight? *

As accurate as possible

Medical reports can be pulled from 2 up to 15 years of medical history as we recommomend that you list all/any findable medical conditions expereinced. This will help us together find the best solution for you will the most effective outcomes.

If we have the most accurate details now, upfront, it will minimize what we will have to ask for later. Thank you for your trust.

Any MAJOR Health Conditions? *

When were you diagnosed? How long have you had it?

Any MINOR Health Conditions? *

When were you diagnosed? How long have you had it?

Health Continued ...

Let's take a look at your medications.

What medications do you take? What dosage of each are you taking? What are you taking them to treat (cause)?

(Pharmaceutical reposts may be viewed by some insurance companies.)

Are you taking any Medications? *

Name, Dosage, and Cause ... List all here please

Any Additional Comments?

Your Doctor / Physician

Your doctor updates your medical chart with every visit and some insurance companies pull this information to verify your application. Accuracy is recommended.

Doctor's Name *

Doctor's Phone Number

Current office number can be listed.

Doctor's Office Name *

Doctor's Address *

Current office address can be listed.

When was your last Doctor visit?

Hosptial visits can be included.

What was the reason for your last doctor visit? *

Hospital visits can be included.

Financial Facts

These facts will help us find an affordable solution for you.

Do you pay a Mortgage / Rent?

ie: Monthly Payment, Lender, Interest Rate, Balance

Do you pay any Auto Loans?

ie: Monthly Payment, Lender, Interest Rate, Balance

Do you have any Credit Cards?

ie: Monthly Payment, Lender, Interest Rate, Balance, Limit

Do you have any Personal Loans

ie: Monthly Payment, Lender, Interest Rate, Balance, Full Amount of Lending

Do you have any Student Loans?

ie: Monthly Payment, Lender, Interest Rate, Balance, Full Amount of Lending

Monthly Expense Breakdown

Here we will calulate the percentage of your income that is occupied by your debt and expenses.

Food Expenses

Property Insurance / Taxes

Auto Insurance

Automotive Gas & Maintenance

Ultilies (Gas, Electric, Water)

Cable / Internet

Phone / Cell Phone

Entertainment (Activities, Movies, TV, Sport Games)

Gym Membership

Gifts / Holidays

TIthes / Charity

Other Expenses

Your Income

Let's add up all of your sources of income toward your net worth.

Annual Income *

$

Bonus Income / Commission

$

Rental Income

$

Other Income

$

Savings Account Balance

$

Monthly Average

Checking Account Balance

$

Monthly Average

Bank CD (Certifcate of Deposit)

$

Money Market Balance

$

Any Medical Plans?

Do you have a Medicare Plan or Suppliment Plan?

Yes

No

Do you have a Medicare Advantage Plan?

Yes

No

Any Other Financial Facts that you'd like to list?

Your Assets

Any Existing Annuities?

Amount, Term, Company, Percentage of Growth

Any Existing Life Insurance? *

Amount of Coverage, Premium, Length

Do you have any existing Retirement Plans?

ie: 401K, 403B, IRA, Roth, TSP, Pension

Do you have an Education Fund?

ie: 529 ... for college, trade school, certification, or license

Do you have any Stocks / Assets?

Your Contribution

Min Premium toward your plan

$

An amount that is easily affordable without worry

Max Premium toward your plan *

$

Stretching for the best value and benefits

Coverage Face Amount

$

How much coverage do you desire?

Do you have a Will? *

Yes

No

Last Step → SUBMIT

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