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QUESTIONNAIRE ENLARGED FOR DETAIL

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Questionnaire

 
 
 

Sample Questionnaire Pages

 
  20.  Do you and the working members of
         your household have adequate
         disability income insurance coverage?
         o  Yes     o  No o  Not sure
         o  Not applicable.  I don't have any
         work-related income, or I am retired.

  21.  Do you have adequate homeowner's
         insurance coverage?
         o  Yes     o  No o  Not sure

  22.  Do you have adequate additional
         insurance protection for valuables
         (jewelry, silverware, etc.)?
         o  Yes     o  No o  Not sure
         o  Not applicable.  I don't currently
         own any valuables.

  23.  Do you have a personal liability
         (umbrella) insurance policy?
         o  Yes     o  No o  Not sure

  24.  Do you have professional liability
         insurance?
         o  Yes
         o  No, but I think I should
         o  Not sure
         o  Not applicable.  My occupation
          doesn't require professional liability
         insurance, or I am retired.

  25.  Have you had difficulty obtaining
         a loan or credit card recently?
         o  Yes     o  No

  26.  Are you considering making a major
         purchase within the next few years?
         o  Yes, a home
         o  Yes, a car
         o  Yes, home improvements
         o  Yes, something other than a home,
         car, or home improvements
         o  No

  27.  Do you have a home equity loan or
         second mortgage on your home?
         o  Yes    o  No, but I'm considering it
         o  No     o  Not applicable, I am not
         a homeowner.

  28.  How did you purchase your last car?
         o  I paid cash or it was a gift
         o  Loan of three years or less
         o  Loan of greater than three years
         o  Lease
         o  Not applicable.  I don't own a car.

 

SAVING AND
  INVESTING

  29.  Including contributions you make to
         retirement accounts, (for example,
         IRA's, 401(k) plans, and 403(b) plans)
         but excluding any employer contri-
         butions, how much of your gross
         employment income do you save?
         (If you are retired, indicate how much
         of your gross retirement income you
         are saving.)
         o  None
         o  Less than 5%
         o  5-10%
         o  11-20%
         o  Over 20%

  30.  If you have children, are you concerned
         about being able to meet their
         education costs?
         o  Yes     o No
         o  Not applicable.  I don't have
         children, or my children are through
         school.

  31.  Are you currently saving for your
         children's education?
         o  Yes     o  No, but we plan to
         o  No      o  Not applicable, I don't
         have children. or my children are
         through school.

  32.  Most investors divide their investments
         among three major categories:
         stocks, bonds, and short-term
         interest-paying securities.  Of all the
         investments you own (both retirement
         and non-retirement accounts, but
         excluding any real estate) approxi-
         mately what percentage is invested
         in stocks and mutual funds that invest
         in stocks?  ____________%

  33.  Who selects your investments?
         o  I and /or other family members do
         o  My broker or investment advisor
         o  Both myself and my broker or
         investment advisor
         o  Not applicable.  I currently 
         don't have any investments.

  34.  Do you review your investments
         periodically?
         o  Yes     o  No
         o  Not applicable.  I currently don't
         have any investments.

 

 
 


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