FINANCIAL SERVICES QUESTIONNAIRE
 
Financial Planners, Investment Advisors, Life Insurance Agents and Registered Representatives
 
 
 
 
 
 
Firm Name:*
 
 
CRD #
 
 
 
Year Established:
 
 
 
 
Address:*
 
 
Total # of Professionals:*
 
 
 
City:*
 
 
County:
 
 
 
State:*
 
 
ZIP Code:*
 
 
 
Contact First Name:*
 
 
Contact Last Name:*
 
 
 
Title:*
 
 
 
 
Phone:*
 
 
Email:*
 
 
 
 
 
 
Type of Entity (Check all that apply):
 
Financial Planner
 
 
Investment Advisor Representative
 
 
 
Registered Investment Advisor
 
 
Life Insurance Agent
 
 
 
Registered Representative
 
 
 
 
Other
 
 
If other entity, please specify:
 
 
 
 
 
 
Limit of Liability Desired:*
 
 
Deductible:*
 
 
 
 
 
 
 
FINANCIAL SERVICES QUESTIONNAIRE
 
 
 
 
 
 
Split Revenues Into the Following Categories:
 
 
 
Last Fiscal Year
 
 
 
 
Commissions:
 
Mutual Funds, Variable Annuities and Variable Life:
 
 
Stocks, Bonds & Other Fixed Income Securities:
 
 
 
Life, Health, Disability Insurance & Fixed Annuities:
 
 
Other Commissions (Describe):
 
 
 
 
 
 
Fees:
 
 
Financial Planning:
 
 
Total Assets Under Management:
 
 
 
 
 
 
Money Management - Non-discretionary:
 
 
Total Assets Under Management:
 
 
 
 
 
 
Money Management - Discretionary Mutual Funds Asset Allocation:
 
 
Total Assets Under Management:
 
 
 
 
 
 
Money Management - Full Discretion - All other securities:
 
 
Total Assets Under Management:
 
 
 
 
 
 
Other Fees (Describe):
 
 
Total Assets Under Management:
 
 
 
 
 
 
Total Revenue for Last Calendar Year (Commissions & Fees):*
 
 
 
 
 
 
Total Projected Revenue for Next Calendar Year:*
 
 
Total Managed Assets for Next Calendar Year:*
 
 
 
 
 
 
 
FINANCIAL SERVICES QUESTIONNAIRE
 
 
 
 
 
 
Has any claim, suit, or arbitration been made against the firm or its professionals?*
 
Yes
No
 
 
 
Number of Closed Claims:
 
 
Amount Paid:
 
 
 
Number of Open Claims:
 
 
Amount Reserved:
 
 
 
 
 
 
Has the firm been disciplined by any regulatory agency?*
 
Yes
No
 
 
If Yes, Agency:
 
 
 
 
Number of Times:
 
 
Fines:
 
 
 
 
 
 
 
FINANCIAL SERVICES QUESTIONNAIRE
 
 
 
 
 
 
Upload current E&O policy, binder or certificate of insurance -OR- complete the information below.
 
 
 
Current E&O Coverage?
 
Yes
No
 
Insurer and Inception Date:
 
 
 
Limit of Liability:
 
 
Deductible:
 
 
 
Premium:
 
 
Retro Date (mm/dd/yyyy):
 
 
 
 
 
 
Upload current cyber policy, binder or certificate of insurance -OR- complete the information below.
 
 
 
Current Cyber Coverage?
 
Yes
No
 
Insurer and Inception Date:
 
 
 
Limit of Liability:
 
 
Deductible:
 
 
 
Premium:
 
 
Retro Date (mm/dd/yyyy):
 
 
 
 
 
 
Current Bonds?
 
Yes
No
 
 
 
If Yes, list the type of Bonds, Premium, Inception Date, and Insurer of each Bond
 
Bond #1:
 
Type:
 
 
Premium:
 
 
 
Inception Date:
 
 
Insurer:
 
 
 
 
 
 
Bond #2:
 
Type:
 
 
Premium:
 
 
 
Inception Date:
 
 
Insurer:
 
 
 
 
 
 
List any special requirements