This is a basic questionnaire that will provide us with a global understanding of your situation. Upon receipt, we can customize a file and block out time to connect with you. Should you have any questions, please do not hesitate to give Jay Weinberg, CLU ChFC a call (609) 432-8862.

Please go to our website at www.pgy3.com for educational content.

Client Questionnaire

First Name(Required)

Last Name(Required)

Personal Email(Required)

Business Email(Required)

Phone #:(Required)

How did you learn about us?(Required)

Occupation

1. What is your medical specialty?(Required)

2. Do you plan to be certified in multiple specialties? If yes, please specify.(Required)

3. Are you a student, resident, fellow or currently practicing?(Required)

4. If you are currently in training, what is the anticipated month/year of graduation?(Required)

5. What school/hospital/institution/employer are you currently affiliated with?(Required)

6. If you have a job lined up, what is the name of your upcoming employer?(Required)

7. When you are practicing, do you expect to be in an academic setting or a private practice setting?(Required)

8. What is your annual earnings potential in 10 years?(Required)

9. What state do you currently live in?(Required)

10. What state or geographical area do you plan to practice in?(Required)

General/Medical

1. What is your date of birth?(Required)

2. What is your sex?(Required)

3. What is your height and weight?(Required)

4. Do you have any pre-existing medical/psychological conditions? If yes, please explain.(Required)

5. Have you had any surgeries in the past 10 years? If yes, please explain.(Required)

6. Do you currently take any medicine? If yes, please list and explain.(Required)

7. Have you been on any medications in the past 3 years (other than antibiotics)? If yes, please list and explain.(Required)

8. Have you used tobacco or nicotine products in past 12 months?(Required)

9. Are you in the military? If yes, active or reserves?(Required)

Student Loans/Debts

1. Do you have student loans? If yes, please list amount and interest rates.(Required)

2. Are you currently paying on your student loans? If yes, which repayment plan (IBR, PAYE, REPAYE or 10 yr.) and how much per month?(Required)

3. Are you hoping to be eligible for any loan forgiveness programs?(Required)

4. If going for PSLF, have you recently completed an Employment Certification Form?(Required)

5. Are you single, married and/or have dependents?(Required)

6. If married, what does your spouse do for a living?(Required)

7. If married, does your spouse have government student loans?(Required)

8. If your spouse has student loans, how much do they have?(Required)

9. If your spouse has student loans, are they going for PSLF?(Required)

10. If married, do you file your income taxes joint or separate?(Required)

11. Do you rent or own where you live? If you own, did you use a physician mortgage, FHA or conventional mortgage?(Required)

Would you like a recommendation for an Accountant?(Required)

Would you like a recommendation for an Employment Contract Attorney?(Required)

Would you like a recommendation for an Physician Home Mortgage Specialist?(Required)

Name

This field is for validation purposes and should be left unchanged.