Financial Success Survey

Instructions: Complete the form below in detail and submit it for review.

Employer

Enter your employer's company name.

First Name *

Enter your first name.

Last Name *

Enter your last name.

Address

Street Address *

Enter your street address.

City *

Enter the city you live in.

State *

Enter the state you live in.

Country

Enter the country you iive in.

Postal Code *

Enter the postal code where you live.

What is your current age? *

What is your current age?

Financial Information Instructions: Using the star ratings below, rate your current financial situation. (Terrible = you're not doing well at all, Awesome = your finances are doing great)

Are you an:

1. How much do you suffer from financial losses as a result of the current economy circumstances? *

Not SufferingSuffering Greatly

2. How concerned are you about your bills or debts? *

Not ConcernedVery Concerned

3. How current are you with your bookkeeping and finances at home? *

Very LateUp to Date

4. How current are you with your bookkeeping and finances at your business? *

Very LateUp to Date

5. How current are you with your tax returns and tax filings. *

Very LateUp to Date

6. How much do you use a Customer Relationship Management System (CRM) to track your leads and customers? *

Not UsedAll the Time

7. How many savings and investment accounts do you currently have? *

010

8. How prepared are you for your children's college education? *

Not PreparedQuite Prepared

9. What level will you suffer from not having enough protection in the case of disability, long-term illness, or event death? *

010

10. How many children, aging parents, or other dependents are you currently supporting? *

010

11. Rate yourself on what level of understanding of financial concepts that involves debt, insurance, investments, inflation, and tax saving strategies do you currently have? *

010

12. What level of importance is having a better return when it comes to planning for your savings and investments? *

010

13. What level of importance is being safe when it comes to your planning for your savings and investments? *

010

14. What is your interest level in learning about how to get your children into a good college without having to worry about where the money is going to come from? *

010

15. What is your interest level in learning more about how money works and how to build a strong financial future? *

010

16. How would you rate your interest in having me do a Financial Needs Analysis with you to create a roadmap for your finances? *

010

17. What is your interest level in making more money and changing how you are currently making it? *

010

18. How coachable and teachable are you on a scale of 1 to 10? *

010

19. I am currently recruiting for new agency partners. If I were to offer you the possibility of working with me in my agency, what would your interest level be in working with me and my firm? *

010

20. One a scale of 1-10 where 1 is I'm not interested and 10 is I'm very interested. How interested are you in getting my help with my finances and taking achieving the goals that are important to me in my life. *

010

Your Total Score:

Here's your score.