Email

info@newerahealthandlife.com

Contact

205-464-9284

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- Nelson Nash
- Nelson Nash Institute
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About
- Nelson Nash
- Nelson Nash Institute
What is IBC
Shop
Contact Us

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Become a Client

"*" indicates required fields

Step 1 of 5

20%

Name (as it appears on your license)*

First Last

Do you go by another name?*

Yes

No

Phone

Email

Are you a U.S. citizen?*

Yes

No

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Marital Status*

Married

Single

Separated

Divorced

Widow

Widower

Other

Do you have children?*

Yes

No

Basic Financial Questions

Are you employed or retired?*

Employed

Retired

Other

Gross Annual Income

2023's Income Estimated*

$

2022's Income

Do you have other income sources?*

Yes

No

Do you save 10% or more?*

Yes

No

Additional Information

Select the assets you have (Select all that apply)

Cash Savings

401k

IRA

ROTH IRA

403b

TSP Plan

Pension Plan

529 Plan

Annuity

Money Market Accounts

C.D.s

Stocks

Bonds

Mutual Funds or Managed Portfolios

Cash Value

Other Assets

(Fill in the amounts below)

Primary Residence Value

(Renters indicate monthly rent amount)

Balance Owed:* $

Do you own investment property?*

Yes

No

Liabilities*

Student Loans

Credit Card Debt

Auto Loan Balance

Other

None

(Select all that apply)

Have you ever filed bankruptcy?*

Yes

No

Policy Information

Desired use for your new policy:*

Capital Accumulation

Debt Elimination

Real Estate Investing

Retirement Income

Legacy Building

Other

If you selected multiple which desired use is your main priority?

Share with us a little bit more about what you would like to accomplish with your policy.*

Goals*

(What are you trying to achieve by using the Infinite Banking Concept®?)

Timeline to start your policy?*

ASAP

1 Month

2 Months

3 Months(+)

TBD

How much premium would you like to pay?*

Would you like to pay monthly or annually?*

Monthly

Annually

TBD

Who is the beneficiary?

Do you have life insurance?*

Term Life Insurance

Whole Life Insurance

Universal Life Insurance

Employer-Provided

None of the above

(Fill in the amounts below)

Assets

Have you ever used nicotine?*

Yes

No

This includes ANY nicotine product. (Cigarettes, Snus, Dip/Snuff, Cigars, Pipe Tobacco, Cigarillos, Inhalers, Patches, Gum, Lozenges, E-Cigarettes/Vapes of all types, Hookah, etc.)

Do you have primary physician?*

Yes

No

Do you have travel outside of the U.S. or Canada scheduled in the next two years? *

If yes, all locations and dates required.

File Uploads

If you would like us to review any illustrations, please upload it here.

Drop files here or

Max. file size: 50 MB, Max. files: 15.

Please upload your Driver's License or State ID here and any medical documentation.

Drop files here or

Max. file size: 50 MB.

We only need the front of the license/ID. Medical records could reduce underwriting time by as much as 30 days. Call a team member for details at 205-464-9284

Just a few more things!

Please choose from the drop-down menu how you heard about us.*

Have you read R. Nelson Nash's "Becoming Your Own Banker?*

Yes

In The Process

No

Have you watched our "Becoming Your Own Banker Book Review?*

Yes

No

Do you own one or more IBC® policies?*

Yes

No

Last question! Are you a licensed Life Insurance Agent or Advisor?*

Yes

No

Today's Date*

MM slash DD slash YYYY

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Contact Us

205-464-9284
info@newerahealthandlife.com
2315 9th St Suite 4-C,
Tuscaloosa, AL 35401

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About
- Nelson Nash
- Nelson Nash Institute
What is IBC
Shop
Contact Us

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