Private Retirement Option General Request Form

Please complete the following request form to receive FREE information on Private Retirement Options. Please note: All fields must be completed.

  City:         State/Province: 
  Zip Code:   
  Home Phone:   
  Work Phone: 
  Your date of birth:     
     Non-Smoker   Smoker

  Spouse's date of birth: 
     Non-Smoker   Smoker
  Your tax bracket is:
     28%    31%    36%    39.6%    Unknown
  I consider myself a:
     Aggressive Investor    Moderate Investor   
     Conservative           Willing to accept NO risk  

  Are you a mutual fund investor?
     Yes    No
  NOTE:  These plans generally require contributions over 5 years.  
  The investment frequency is flexible and can be made annually, semi-annually, 
  quarterly and/or monthly (electronic transfer only) or anytime you wish.

  Amount you may want to consider investing: 
     Single    Quarterly    Semi-Annually    Annually

  For how many years (5 years minimum): 

  Your estimated time frame to purchase a universal life policy is?
     Less than one month    1 to 3 months    3 to 6 months
  Your general awareness on this subject is:
  Are you a Financial Advisor? (RIA, stockbroker, insurance agent, fee planner):
  Additional Comments/Questions:


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All Rights Reserved.

Securities offered through Fortune Financial Services, Inc. member FINRA, SIPC.  Fielder Financial Management, Ltd. not affiliated with Fortune Financial Services, Inc.  Mark Fielder, Financial Professional, CA. Insurance Lic. # 0690576.