Periodic Review Survey

Contact Information

* Required fields
Name: *	This field is required
Address:
City:
State:
Zip:
Phone:
E-mail:
Company:

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Status Changes

Family Status Change: (check all that apply)
Married Divorced Child Grandchildren	Death in Family Partnered Other
Employment Status (check all that apply)
Employed Self-Employed Unempolyed Retired	Changing Jobs Pending 401(k) Rollover Promotion Loss of Benefits

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Interests and Concerns

I would like information on or wish to discuss the following: (check all that apply)

Preparing or Updating a Financial Plan
Estate Planning Needs
Retirement Income Planning
Income replacement In Case of Disability
My Children's College Expense Funding
Business Planning Needs
Pension or Qualified Plan Distributions
Mutual Fund Investing
Tax Deferred Annuities
Review My 401(k) Plans
Long-Term Care Needs Planning
Reviewing My Insurance Needs
IRAs - Traditional vs Roth
Reviewing My Policy and Account Information
Review/change my investment allocations
Transfer funds within my investment options
Review a Loan
Review/change my beneficiary assignment

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Asset Allocation

	Yes*	No
Have you changed your feelings about investing in the market?
Have your liquidity needs changed?
Has your time horizon for investing changed?
Do you feel that your assets are correctly allocated for your needs?
Would you like to explore other investment options?
* If the answer to any of these questions is yes, we should schedule an asset allocation analysis.This analysis is complimentary and a service to you as a valued client
Would you be interested in any of the following: (check all that apply)
	Yes	No
Preparing or updating a financial strategy?
Tracking and evaluation of investments held elsewhere?
Submitting a Risk Tolerance Questionnaire to supplement this Periodic Review?
Submitting a Client Profile to supplement this Periodic Review?

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Recommendations

	Yes	No
Has our firm delivered a level of service that would lead you to recommend us to a friend or family member?
May our firm use your name as a reference?

Other Issues and Concerns:
Please use the space provided to ask questions or raise issues not addressed in this checklist.

If you would like to recommend us to a business associate, friend or family member - please do so below:
Name 1:
Phone 1:
E-mail 1:

	Yes	No
May I use your name as a reference?

Name 2:
Phone 2:
E-mail 2:

	Yes	No
May I use your name as a reference?

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Follow Up

How often would you like to review and discuss your financial goals, objectives and progress?

Once a Quarter
Semi-Annually
Once a Year
Other

Thank You!

I would like to take this opportunity to thank you for your continued trust and business, and for completing this Periodic Review Survey.

This survey is an affirmation of my commitment to help you meet your ongoing financial needs and providing a high level of personalized service.

This Periodic Review is designed to help determine the areas in which you have interests and concerns.It will allow me to update your files and service your needs more completely.Information provided will be kept in the strictest confidence.

GE-61007 (02/11)