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 About youAbout Your Spouse/Partner
Title
Firstname
Surname
SexMaleFemale MaleFemale
Date of Birthday/ month/ yearday/ month/ year
Email
Housename/number
Address
Town
County
Postcode
Daytime Number
Evening
Mobile
Occupation
EmploymentEmployed Self Employed Employed Self Employed
Company Director Retired Company Director Retired
Marital StatusMarried Single Married Single
Divorced Widowed Divorced Widowed
Do you have any children?YesNoYesNo

About your home 
Do you own a propertyYesNo
If yes, what is the approximate value?£
Do you have a mortgage?YesNo
If yes, how much is outstanding?£
About your savingsAbout youAbout Your Spouse/Partner
Deposits
Bank/Building Society savings
£
£
TESSAs
£
£
National Savings££
Guaranteed Bonds££
InvestmentsGovernment Stocks (Gilts)££
Shares££
Unit Trusts/
Investment Trusts		££
Personal Equity
Plans (PEPs)		££
Individual Savings Account (ISAs)££
Investment Bonds££
Others (please specify)
£
£
£
£
£
£
£
£
Regular SavingsAbout youAbout Your Spouse/Partner
What is the amount?£pa £pa
About your incomeAbout youAbout Your Spouse/Partner
Earned Income (before tax)£pa£pa
Paid by:    
Pension Income (before tax)£pa £pa
Investment Income (before tax)£pa £pa
About your future incomeAbout youAbout Your Spouse/Partner
Are you contributing to a pension?YesNo YesNo
If so what type?
Employer's
Personal
Employer's
Personal
AVC/FSAVC
AVC/FSAVC
Your financial objectivesAbout youAbout Your Spouse/Partner
Maximise Income
Capital Growth
Retirement Planning
Inheritance Tax Planning
Offshore Investments
Provision for Long Term Care
Other (please specify)
Financial Advice About youAbout Your Spouse/Partner
Do you have an existing financial adviser?YesNoYesNo
If yes, What is their name?
Please mark your attitude to investment risk on the following scale
About you
About Your Spouse/Partner
LowBalancedHigh
LowBalancedHigh
Amount currently available for investmentAbout youAbout Your Spouse/Partner
How much do you want to save?££
Lump Sum££
Regular Saving££
Per monthPer annumPer monthPer annum
Where is it now?
When is it available?
Over what period?About youAbout Your Spouse/Partner
Number of years0-55-1010+ 0-55-1010+
Any other comments or information that may be useful to us.
Head Office & Registered Office:
536 Coventry Rd Small Heath, Birmingham B10 0UN
Registered in England (3647203)John Russell Insurance Services Copyright 2008