FINANCIAL PLANNING

QUESTIONNAIRE

STRICTLY PRIVATE AND CONFIDENTIAL – CLIENT DETAILS

Member client number:

Surname: Title: Mr Mrs Ms Miss Dr

Given names: Date of birth: (DD/MM/YYYY) / /

Preferred name: Relationship status:

Partner’s client number (if applicable):

Partner’s surname: Title: Mr Mrs Ms Miss Dr

Partner’s given names: Date of birth: (DD/MM/YYYY) / /

Partner’s preferred name:

Address:

State: Postcode:

Preferred contact method: Telephone (home) Telephone (work) Mobile Email

Telephone (home): Telephone (work):

Mobile: Email:

ES_FPQ_0314
ABOUT THIS QUESTIONNAIRE
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Do not be concerned if you are unsure how to complete a question as your adviser will discuss your situation
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1. YOUR LIFE GOALS

We want to help you achieve your life goals but to do so we need a general understanding of your situation
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a. Your goals
Goal Estimated funds required Target date )UHTXHQF\
Home/property purchase $
Home renovation $
Holiday/travel $
Car/boat/caravan $
Children’s education/wedding $
Pay off mortgage/debts $
Other (specify) $
Other (specify) $
Total Funds Required $

Notes/Comments:

1
 b. Your personal plans
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Estimated retirement income Expected retirement age
<RXUSODQ $
Partner’s plan $
Total Plans $

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2. YOUR DEPENDANT’S DETAILS

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Name Date of birth Relationship to you 'HSHQGDQW"<HV1R Date/age support
will end

Notes/Comments:

2
3. YOUR EMPLOYMENT (please ignore question a if you are not working)

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Current occupation
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Employer name
Date commenced

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resignation, redundancy, relocation)
Expected date of change
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Planned retirement age
Do you have an accrued long
service leave entitlement,
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4. ANNUAL SALARY AND INCOME

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Base salary or wage (gross) $ $
Total salary or wage (gross) $ $
Packaged items (list) $ $
$ $
$ $
7RWDO:DJHRU6DODU\ $ $

b. Other Income Your other income Partner’s other income

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,QYHVWPHQWV"DQQXDOLQFRPH $ $
%XVLQHVV"DQQXDOLQFRPH $ $
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Total Other Income $ $

Notes/Comments:

3
5. YOUR ANNUAL EXPENDITURE (what you spend)
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in Appendix 1

a. Annual Expenditure Your expenditure Partner’s expenditure

Total Annual Expenditure $ $

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Notes/Comments:

6. ASSETS (what you own)

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D<RXU/LIHVW\OH$VVHWV Owner/s Current Value

Principal residence (home) $
Household contents $
Car/s $
Other (boat, caravan etc) $
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b. Cash, Savings, or Term Deposits

Bank/Institution Account type Owner/s Interest rate Maturity date Current value
$
$
$
$
Total Cash Assets $

4
How much money do you need in readily cashable investments to meet emergencies
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c. Your Investment Assets

Name or Description Owner/s Date of Original No of units Current
of Shares, Property, investment investment $ or shares value $
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$ $
$ $
$ $
$ $
$ $
$ $
$ $
Total Other Assets $ $

d. Other Entities You Your partner

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Notes/Comments:

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Notes/Comments:


7. YOUR SUPERANNUATION / EMPLOYMENT TERMINATION PAYMENTS /
ROLLOVERS NOT RELATED TO ENERGY SUPER
Please include all superannuation, superannuation life policies, employment termination payments and/or rollover
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d. Fund or Product Owner Current value

Name/Description
 $
 $
 $
 $
 $
 $
 $
 $
Total Amount $

Have you or anyone else made contributions for you to any superannuation funds (apart from Energy Super)
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Please provide details:

6
8. LIABILITIES (what you owe)
Please provide the following information so that we can calculate how much you have to invest and your current
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Description Owner 7\SHDQG Date loan Original Interest 0RQWKO\ Interest tax Current
term commenced amount rate % UHSD\PHQW GHGXFWLEOH" amount
owing

Mortgages %

$ % % $ $
$ % % $ $
$ % % $ $
Other
loans, credit %
cards, tax:
$ % % $ $
$ % % $ $
$ % % $ $
$ % % $ $
$ % % $ $
Total $ % $ $
Liabilities

Notes/Comments:

9. YOUR HEALTH

Your health Your partner’s health

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Please provide details:

7
10. YOUR INSURANCE (not related to Energy Super)
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a. Life Insurance Your cover Estimated Your partner’s Estimated

premium (if known) premium (if known)
Death cover
Total and
permanent disability
Income protection
Critical illness/
trauma
Whole of life/
endowment
Other insurance

b. General 7\SHRIFRYHU Insured value Estimated Date last reviewed

Insurance (replacement or premium (if known)
residual)
Home
Contents
Motor vehicle
(comprehensive
or third party)
Private Health
(hospital/extras)
Landlord’s
insurance
Other insurance
(business)

11. YOUR ESTATE PLANNING

a. Wills You Your partner

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Have your circumstances changed
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Does your will include
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 b. Other important matters You Your partner
Have you executed an enduring
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(name of your attorney)
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Do you have an Advanced
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Do you have children from previous
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Are there any other special
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Are any of your potential
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Notes/Comments:

12. ACKNOWLEDGEMENTS
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I/We authorize you to contact the advisers, insurance companies, superannuation fund administrators, banks, credit
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I authorise Energy Super and ESI Financial Services to provide me with Product Disclosure Statements,
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Notes/Comments:

9
14. ADVISER DECLARATION
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I have explained to the client the relevance of determining their risk tolerance with regard to establishing
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Adviser Name

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service providers and, if you are a member, to Energy Super and their service providers (including Independent
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disclose your personal information in order to:
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We generally collect your personal information directly from you but may also collect it from other orgainisations
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10

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APPENDIX 1 – GUIDE TO CALCULATING YOUR EXPENDITURE

a. Expenditure Your expenditure Partner’s expenditure

Mortgage or rent $ $
Local rates and taxes $ $
Household (food, electricity, $ $
telephone etc)
Car, boat, transport $ $
Clothing, personal $ $
Education $ $
Entertainment $ $
Insurance (life, general, medical) $ $
Medical, dental $ $
Loans, credit cards $ $
Other $ $
Other $ $
Total Expenditure $ $

CONTACT DETAILS

ESI Financial Services Pty Ltd

AFSL 224952 ABN 93 101 428 782
MAIL
GPO Box 1006
Brisbane QLD 4001
ADDRESS
Level 8
100 Creek Street
Brisbane QLD 4000
PHONE
1300 436 374
FAX
(07) 3231 6267
EMAIL
[email protected]
FPQ 01_v8 MAR 2014

11