New Client Form

Please only complete this form after talking to a member of Privatenomics.

Use this form to submit necessary personal and financial information ONLY. If you're a first-time visitor to Privatenomics, please go back and fill out the Get in Touch form instead.

Primary Client Details

Legal First Name *

Legal Last Name *

Are you a U.S. citizen? *

Date of birth *

Sex *

Primary Residence *

City *

State *

Postal code *

Best Phone Number *

Email *

Marital Status *

How many children do you have? *

How many grandchildren do you have? *

Cashflows

Asset 1

Asset 1 *

Current Value *

$

Notes

Asset 2

Current Value

$

Notes

Asset 3

Current Value

$

Notes

Asset 4

Current Value

$

Notes

Liabilities

Does your household carry any debt (including a mortgage) owed to conventional lenders? *

You may exclude temporary credit lines, balances on which you extinguish at the end of the monthly pay period, and any outstanding policy loans.

Your Household Net Worth (Auto-Calculated - No entries Required

Total Assets *

$

Total net value of any permanent insurance is excluded in this calculation.

Total Liabilities

$

Net Worth

$

Your Life Insurance

Do you (or your spouse, if applicable) own any permanent life insurance? *

For example: participating (i.e dividend-paying) whole life insurance, non-participating (non-dividend-paying) whole life insurance, universal life, variable universal life, indexed universal life, or equity indexed universal life.

Do you (or your spouse, if applicable) own any temporary (i.e term) life insurance? *

Does anyone else own temporary or permanent life insurance where you are or your spouse is the insured person (i.e. an 'other-owned' policy)? *

Basic Underwriting Questions: Bankruptcy

Have you filed for bankruptcy within the past 10 years? *

Basic Underwriting Questions: Nicotine

Have you ever consumed nicotine products? *

Basic Underwriting Questions: Cannabis

Have you ever consumed cannabis products? *

Basic Medical Information: Primary Client

Have you been seen by a licensed medical professional within the past five years? *

Primary IBC Considerations

Based on your current overstanding of Nelson Nash's Infinite Banking Concept, how much in total premium outlay do you think is appropriate? Please keep in mind that we are not necessarily married to this number. Anterio may refer to this number as an example in order to help apply the general idea of premium outlay to your specific circumstances. *

$

Where to find us?

privatenomics

You must have an appointment scheduled to connect with us. Please click the "Get In Touch" button above and fill out the form to schedule an appointment.