Wealth Build Intake Form
First Name
*
Last Name
*
Email
*
Phone
*
Date of birth
*
Your Gender?
*
Gender (Please Select):
Female
Male
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Tobacco User?
*
Tobacco User (Please Select):
No
Yes
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Describe your health?
*
Health Status
Good
Average
Poor
Some medical diagnosis's
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State
*
Length of time you have to save (Only permanent policy's will allow you to be your own bank)
*
Length of time
10 years
15 years
20 years
30 years
Permanent never expire
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Types of meds
*
Recent stays at facilities
*
Details about your health?
*
Health conditions known
Health diagnoses (if yes, please list below)
Affordable monthly bank deposits
*
Amount
$200-$400
$450-$600
$650-$800
Maximum
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What age would you like to take start taking withdrawals from your bank?
*
Do you have a lump sum deposit from a retirement fund?
*
Will you be using a child in your family to start this banking concept of wealth?
*
Yes
No
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If yes, please put the age of the child
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