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Online assessment form
  Clemence Hoar Cummings
  Financial Services
 

Free provisional assessment

As Independent Financial Advisers we are not 'tied' to any insurance company or investment house, which means that we can survey the entire market place when advising on the products best suited to your needs. We will initiate a full and unbiased review of your financial affairs and plan an overall strategy for you recommending the best options for your particular circumstances.

In order to provide sound financial advice we need a general understanding of your existing situation and we normally recommend a preliminary meeting at our offices. However, as this is not always practical or possible, we have designed this form, which should provide the basic information we need to make a provisional assessment. Please complete it as thoroughly as possible and press the "Submit" button at the end or print it out and fax it to us 01708 333311.

Please be sure to include your telephone number(s) and suitable times for contact, as we may need to clarify some points.

Fields with an asterisk * must be filled in for preliminary online assessment.
About You  
Full name: *
Date of birth: *  
Format - dd / mm / yyyy
Smoker? *
Yes No
Full name: spouse
Date of birth: spouse  
Format - dd / mm / yyyy
Smoker?
Yes No
Your postal address :  
Street name and house number/name : *
Town : *
County : *
Post code : * Capitals please
E-Mail Address : *
Contact number : day *
Contact number : evening *
Marital Status : *
Have you made a will ?
self : Yes No
spouse : Yes No
Employment / Occupation
Occupation : *
Employment type :
 
Occupation spouse :
Employment type spouse :
Total gross income :
self : * pa
spouse : pa
Protection
Existing amount of life cover :
self : *
spouse :
Existing amount of critical illness cover
self : *
spouse :

How long would you receive income if unable to work due to accident/sickness or disability ?
Number of weeks self -
Number of weeks spouse -
Do you have income protection cover * Yes No
If so, what is monthly benefit pm
Does your spouse have income protection cover Yes No
If so, what is monthly benefit pm
Pension Information
Your existing pension arrangements:
Do you have a pension plan ? * Yes No
If so - what type :
What are the regular pension contributions ?
employer contribution : (if applicable) per month
your contribution : per month
Your spouse's existing pension arrangements:
Does your spouse have a pension plan ? Yes No
If so - what type :
What are the regular pension contributions ?  
employer contribution : (if applicable) per month
spouse contribution : per month
At what age do you want to retire ?
self :
spouse :
Investments currently held
self : Bank/building society Gilts
  Shares TESSA's /TESSA ISA
  PEPS / ISA's National savings
  G uaranteed income growth bonds Investment bonds
  Unit trusts / investment trusts  
   
spouse: Bank/building society Gilts
  Shares TESSA's /TESSA ISA
  PEPS / ISA's National savings
  Guaranteed income growth bonds Investment bonds
  Unit trusts / investment trusts  
Property
Do you own your own house ? * Yes No
If so, what is its approximate value ?
Type of Mortgage :
Mortgage amount
Mortgage Rate :
Do you own any other property ? Yes No
If so, what is the approximate value ? Details of outstanding loans - please list :
Property 1 -
Loan 1 -
Property 2 -
Loan 2 -
Priorities
Please indicate your financial priorities using the key below : *
  1. essential
  2. very important
  3. moderately important
  4. not very important
  5. covered or no interest
Financial security for family * Income protection *
Retirement planning * Regular savings *
Invest to increase income * Invest for capital growth *
Inheritance tax planning * Ethical investments *
Repay mortgage(s) or loan * Write a will *
other - please specify
Please indicate your attitude towards risk : *
Please indicate your spouse's attitude towards risk :
Available for investment/pension
Lump sum :
self
When is it available ?
spouse
When is it available ?
 
Regular saving :
self pm
spouse pm
 
Additional information  
Please use this space to give us any further information that you feel may be helpful
Your preferred contact time :
Mon-Friday or weekends
Time of day
You can also fax this form to us if you prefer on - 01708 333311
For further information and an initial consultation without charge or commitment, please contact Neil or Julie on 01708 333310 or email from this link.
* You do not have to be a client of Clemence Hoar Cummings, Chartered Accountants, to benefit from our financial services advice
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Authorised and Regulated by the Financial Services Authority for investment business