Family Legacy Journey - Survey - Ambassador Advisors, LLC

Step 1 of 6

There are 6 sections in this confidential process. You will be automatically redirected to the next step, as you complete the previous one. At the end, you will see a confirmation that your survey is complete.
Before you begin, please collect the following so you can complete the process:
- Employment information
- Account information
- Insurance information
- Loan, mortgage, and credit card information
- Real estate information
- Estate planning documents

If you gather all of your documents and statements now, this process should take you about an hour to complete.
Personal & Contact Information
Name

(First, Middle Initial, Last)
If married, Spouse Name

(First, Middle Initial, Last)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Cell Phone Number #1
Cell Phone Number #2
Email
Email #2
Date of Birth or Age
If married, Spouse Date of Birth or Age
Are you employed?
Employer Name
Employer City and State
Position Title
If you are married, is your spouse employed?
Spouse Employer Name (if applicable)
Spouse Employer City and State (if applicable)
Spouse Position Title (if applicable)
Do you have a financial advisor?
Financial Advisor Name/Company
Financial Advisor Phone Number
Do you have an insurance representative (property/casualty)?
Insurance Representative Name/Company
Insurance Representative Phone Number
Do you have an estate planning attorney?
Estate Planning Attorney Name/Company
Estate Planning Attorney Phone Number
Do you have any other attorneys?
Other Attorney Name/Company
Other Attorney Phone Number
Do you have an accountant?
Accountant Name/Company
Accountant Phone Number
Do you have any other trusted advisors?
Trusted Advisor Name/Company
Trusted Advisor Phone Number
Name of Financial Advisor
Which advisory team do you work with?*
- Bernie Bostwick or Lenny Marsch
- Bob Kauffman, Adrian Young, or Dan Bailey
- Dirk Olds, Merri Sturtevant, or Matt Diers
- Angie Shea or Curtis Musser
- I'm not sure
Who referred you to participate in the Family Legacy Journey?

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Assets
Accounts – All questions apply for you and/or your spouse.
Do you have a Traditional (pre-tax) IRA?
Traditional (pre-tax) IRA Name on Account
Traditional (pre-tax) IRA Primary Beneficiary
Traditional (pre-tax) IRA Contingent Beneficiary
Traditional (pre-tax) IRA Account Number (last 4 digits only)
Please enter a number less than or equal to 9999.
Do you (or your spouse) have another Traditional (pre-tax) IRA?
Name on Account, Beneficiary, and Account Number (last 4 digits only) for additional Traditional (pre-tax) IRA(s).
Do you have a Roth IRA?
Roth IRA Name on Account
Roth IRA Primary Beneficiary
Roth IRA Contingent Beneficiary
Roth IRA Account Number (last 4 digits only)
Please enter a number less than or equal to 9999.
Do you (or your spouse) have another Roth IRA?
Name on Account, Beneficiary, and Account Number (last 4 digits only) for additional Roth IRA(s).
Do you have a SEP IRA?
SEP IRA Name on Account
SEP IRA Primary Beneficiary
SEP IRA Contingent Beneficiary
SEP IRA Account Number (last 4 digits only)
Please enter a number less than or equal to 9999.
Do you (or your spouse) have another SEP IRA?
Name on Account, Beneficiary, and Account Number (last 4 digits only) for additional SEP IRA(s).
Do you have a SIMPLE IRA?
SIMPLE IRA Name on Account
SIMPLE IRA Primary Beneficiary
SIMPLE IRA Contingent Beneficiary
SIMPLE IRA Account Number (last 4 digits only)
Please enter a number less than or equal to 9999.
Do you (or your spouse) have another SIMPLE IRA?
Name on Account, Beneficiary, and Account Number (last 4 digits only) for additional SIMPLE IRA(s).
Do you have a retirement plan through a current or former employer?
Retirement Plan Name on Account
Retirement Plan Primary Beneficiary
Retirement Plan Contingent Beneficiary
Retirement Plan Account Number (last 4 digits only)
Please enter a number less than or equal to 9999.
Do you (or your spouse) have another Retirement Plan?
Name on Account, Beneficiary, and Account Number (last 4 digits only) for additional Retirement Plan(s).
Do you have a non-retirement brokerage or investment account?
Non-retirement brokerage or investment account Name on Account
Non-retirement brokerage or investment account Account Number (last 4 digits only)
Please enter a number less than or equal to 9999.
Do you (or your spouse) have another non-retirement brokerage or investment account?
Name on Account and Account Number (last 4 digits only)for additional non-retirement brokerage or investment account(s).
Do you have a bank CD?
Bank CD Name on Account
Bank CD Account Number (last 4 digits only)
Please enter a number less than or equal to 9999.
Do you (or your spouse) have another Bank CD?
Name on Account and Account Number (last 4 digits only) for additional Bank CD(s).
Do you have a bank checking account?
Bank checking account Name on Account
Bank checking account Account Number (last 4 digits only)
Please enter a number less than or equal to 9999.
Do you (or your spouse) have another Bank checking account?
Name on Account and Account Number (last 4 digits only) for additional Bank checking account(s).
Do you have a bank savings account?
Bank savings account Name on Account
Bank savings account Account Number (last 4 digits only)
Please enter a number less than or equal to 9999.
Do you (or your spouse) have another Bank savings account?
Name on Account and Account Number (last 4 digits only) for additional Bank savings account(s).

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Assets (continued)
Do you have accounts with any other financial institutions?
Other account Name on Account, beneficiary, and account number (last 4 digits only)
Do you have stock options, or a stock purchase plan?
Stock options, or a stock purchase plan Name on Account
Stock options, or a stock purchase plan Account Number (last 4 digits only)
Please enter a number from 0 to 9999.
Do you (or your spouse) have another stock options, or a stock purchase plan?
Name on Account and Account Number (last 4 digits only) for additional stock options, or stock purchase plan(s).
Do you have a custodial or educational savings account for your children or grandchildren?
Custodial or educational savings account Name on Account
Custodial or educational savings account Beneficiary
Custodial or educational savings account Account Number (last 4 digits only)
Please enter a number from 0 to 9999.
Do you (or your spouse) have another custodial or educational savings account?
Name on Account, Beneficiary, and Account Number (last 4 digits only) for additional custodial or educational savings account(s).
Do you have an annuity?
Annuity Name on Account
Annuity Primary Beneficiary
Annuity Contingent Beneficiary
Annuity Account Number (last 4 digits only)
Please enter a number less than or equal to 9999.
Do you (or your spouse) have another annuity?
Name on Account, Beneficiary, and Account Number (last 4 digits only) for additional annuity(ies).
Insurance
All questions apply for you and/or your spouse.
Do you have a life insurance policy?
Life insurance policy Name on Account
Life Insurance Primary Beneficiary
Life Insurance Contingent Beneficiary
Life insurance policy Account Number (last 4 digits only)
Please enter a number less than or equal to 9999.
Do you (or your spouse) have another Life insurance policy?
Name on Account, Beneficiary, and Account Number (last 4 digits only) for additional Life insurance policy(ies).
Do you have a disability insurance policy?
Disability insurance policy Name on Account
Disability insurance policy Beneficiary
Disability insurance policy Account Number (last 4 digits only)
Please enter a number less than or equal to 9999.
Do you (or your spouse) have another Disability insurance policy?
Name on Account, Beneficiary, and Account Number (last 4 digits only) for additional Disability insurance policy(ies).
Do you have a long-term care insurance policy?
Long-term care insurance policy Name on Account
Long-term care insurance policy Beneficiary
Long-term care insurance policy Account Number (last 4 digits only)
Please enter a number less than or equal to 9999.
Do you (or your spouse) have another Long-term care insurance policy?
Name on Account, Beneficiary, and Account Number (last 4 digits only) for additional Long-term care insurance policy(ies).
Do you have a health insurance policy?
Health insurance policy Name on Account
Health insurance policy Account Number (last 4 digits only)
Please enter a number less than or equal to 9999.
Do you (or your spouse) have another Health insurance policy?
Name on Account, and Account Number (last 4 digits only) for additional Health insurance policy(ies).
Do you have military retirement or survivor benefits?
Military retirement or survivor benefits Name on Account
Military retirement or survivor benefits Beneficiary
Military retirement or survivor benefits Account Number (last 4 digits only)
Please enter a number less than or equal to 9999.
Do you (or your spouse) have another Military retirement or survivor benefits?
Name on Account, Beneficiary, and Account Number (last 4 digits only) for additional Military retirement or survivor benefits.
Do you have any other personal insurance policies?
Other Insurance Policy Name on Account
Other Insurance Policy Beneficiary
Other Insurance Policy Account Number (last 4 digits only)
Please enter a number less than or equal to 9999.
Do you (or your spouse) have any other insurance policies?
Name on Account, Beneficiary, and Account Number (last 4 digits only) for additional insurance policy(ies).

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Estate Planning
All questions apply for you and/or your spouse.
Do you currently have Financial and Health Care Powers of Attorney document in place?
Name of Fiduciary or Agent
Date of Power of Attorney document
MM slash DD slash YYYY
Do you (or your spouse) have another Power of Attorney document?
Date and Name of Fiduciary or Agent for additional Power of Attorney document(s).
Do you currently have a Living Will, Health Care Declaration, or Advanced Directive in place?
Name of Fiduciary or Agent on Living Will, Health Care Declaration, or Advanced Directive
Date of Living Will, Health Care Declaration, or Advanced Directive
MM slash DD slash YYYY
Do you (or your spouse) have another Living Will, Health Care Declaration, or Advanced Directive?
Date and Name of Fiduciary or Agent for additional Living Will, Health Care Declaration, or Advanced Directive(s).
Do you currently have a Last Will & Testament in place?
Name of Fiduciary or Agent on Last Will & Testament
Date of Last Will & Testament
MM slash DD slash YYYY
Do you (or your spouse) have another Last Will & Testament?
Date and Name of Fiduciary or Agent for additional Last Will & Testament(s).
Do you currently have any Trust documents in place?
Name(s) of Trustees
Date of Trust documents
MM slash DD slash YYYY
Do you (or your spouse) have any other Trust document(s)?
Date and Name(s) of Trustees for additional Trust document(s).
Three groups can benefit from your estate:
1) family/heirs,
2) ministries/charities, and/or
3) the government (in the form of taxes, at death).

As an estimated percentage, how much does your current estate plan leave to each of these groups?
1) Family/Heirs
- I don't know.
2) Ministries/Charities
- I don't know.
3) The Government
- I don't know.
As an estimated percentage, how much would you like your estate plan leave to each of these groups?
1) Family/Heirs
2) Ministries/Charities
3) The Government
We Can Help!
If the percentages in your current plan do not match the percentages that you wish to leave, we can help you put a plan in place to be sure your finances are distributed as you want.
Special Instructions
In the event of your death, do you or your spouse have special requests/instructions regarding…

You may leave this blank for now and submit it to Ambassador Advisors at a later time if you wish.
Pet care?
Pet care special instructions.
Organ donation?
Organ donation special instructions.
Obituary?
Obituary special instructions.
Write your own obituary (optional).
Funeral service/Burial?
Funeral service preferred minister
Funeral service pallbearers
Funeral service eulogy
Funeral service special songs, music, poetry, etc.
Funeral service: "Donations to _________ in lieu of flowers"
Funeral service other requests.
Tombstone engraving?
Tombstone engraving special instructions.

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Family Legacy Journey – Survey

Step 1 of 6

There are 6 sections in this confidential process. You will be automatically redirected to the next step, as you complete the previous one. At the end, you will see a confirmation that your survey is complete.

Personal & Contact Information

Assets

Assets (continued)

Insurance

Property / Accounts Receivable

Liabilities

Special Circumstances

Estate Planning

We Can Help!

Special Instructions

Special Instructions (continued)