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Business Strategies Personal Agent Match

CONSULT AN AGENT NEAR YOU

Please complete and send the form below and we'll have a New York Life agent in your area contact you at your convenience.

First name*
Last name*
Address*
City*
State*

Zip*
Phone*

Phone Number Area Code - Phone Number First 3 Digits - Phone Number Last 4 Digits
Home or work?Phone Location

Home Work
Best time to call

Best Day To Call Best Time To Call
Birth Date

Date of Birth Month - Date of Birth Day - Date of Birth Year

Why?
(please click only once)
* = required

Please fill out the form below and we will match you up with a New York Life agent in your area that can help analyze your business needs and recommend appropriate solutions through insurance and financial products and concepts.

Information About Your Business

Name of your business?

Nature of the business?

Address

Phone Number (Required)
Area Code and Phone Number

Fax Number
Area Code and Fax Number

E-mail

What is your legal form of business?

Sole proprietorship?
Partnership?
S Corp?
C Corp?


	If yes, what is the tax bracket?

	Number of owners:

	DOB

	Do you have a buy-sell agreement? Yes No

	Is it funded? Yes No

How did you get started in this business?

If you were selling your business today, how much would you ask for it?

Events That Affect Your Business

When you retire, what will you do with your business?


Sell it to a family member?		Sell it to an outsider?
Gift it to a family member?		Close your business?
Sell it to a key employee?

When you retire, where will your retirement income come from?


Pension?		Sale of your business?
Personal savings?		Have not thought about it.

What percent of your total estate is made up by your business?


1/3 or less?		1/2 or more?

In the event of your premature death what would happen to your business?


Would it have to be sold?		Would it have to be close?
I'm not sure!

In the event you became disabled what would happen to your business?


Would you have to sell it?		Continue? For how long?
Would you have to close it?
Not sure?

If you became disabled what would happen to your personal income?


Stop?		Continue? For how long? Paid by?

Information About Your Employees

How many employees do you have?

If any employees are key to your business, how many?

Do you have any supplemental programs to help retain "key" employees, such as Executive Bonus, Non-qualified Deferred Compensation, Salary Continuation?


Yes		No

If you are hiring any additional employees in the next six months, how many?

What is your turnover rate?

Benefit Programs For Your Employees

Do you have a group health plan?


Yes		No


	Company?

	Type: HMO/PPO Major Med Dental Life DI

	Percentage of premiums paid by the business:

	Are you satisfied? Yes No

	Renewal date?

Do you have any qualified or voluntary payroll deduction plans?


Yes		No

If Yes, explain

If you were to increase or provide additional benefits who would you want to benefit most?


Owner-employees		Non-owner employees

With that in mind, pick two of the three items listed below that are most important to you:


Tax deductible to the business		Not currently taxable as income
Pick and choose who benefits

Is providing added value programs important to you?


Yes		No


Your Agent's Name



	What is your agent's name? (If you don't have one, please leave this blank.)

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Business Strategies Personal Agent Match

CONSULT AN AGENT NEAR YOU

Please complete and send the form below and we'll have a New York Life agent in your area contact you at your convenience.

First name*
Last name*
Address*
City*
State*

Zip*
Phone*

Phone Number Area Code - Phone Number First 3 Digits - Phone Number Last 4 Digits
Home or work?Phone Location

Home Work
Best time to call

Best Day To Call Best Time To Call
Birth Date

Date of Birth Month - Date of Birth Day - Date of Birth Year

Why?
(please click only once)
* = required

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