Customer Feedback - Which financial tools are you interested in?

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* 1. Where did you hear about Rempp Financial?

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* 2. Contact Info

First and Last Name *

Company (if applicable)

Address *

Address 2

City/Town *

Province *

ZIP/Postal Code *

Country

Email Address *

Phone Number *

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* 3. What products or strategies are you interested in?

Infinite Banking Concept

Life Insurance - Term

Life Insurance - Whole Life

Return of Premium on Critical Illness

Return of Premium on Disability Insurance

Shared Ownership Critical Illness

Estate Planning

Cash Flow Planning

Replacing GICs with much more efficient products

Getting a TFSA on steroids without contribution restrictions

Putting your RRSP to better use

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* 4. About Yourself

What is your date of birth?

Do you smoke?

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* 5. Family Question: Spouse or Common-Law

What is the name of your spouse?

What is his/her date of birth?

Does he/she smoke?

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* 6. Family Question: Kid #1

What is the name of your first child?

What is his/her date of birth?

Gender (M or F)

Does he/she smoke?

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* 7. Family Question: Kid #2

What is the name of your second child?

What is his/her date of birth?

Gender (M or F)

Does he/she smoke?

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* 8. Family Question: Kid #3

What is the name of your third child?

What is his/her date of birth?

Gender (M or F)

Does he/she smoke?

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* 9. Family Question: Kid #4

What is the name of your fourth child?

What is his/her date of birth?

Gender (M or F)

Does he/she smoke?

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* 10. Do you currently have any life insurance, disability insurance, or critical illness insurance? (other than through work)

	Term Insurance	Whole Life Insurance	Universal Life Insurance	Critical Illness	Disability Insurance
Yourself	Yourself Term Insurance	Yourself Whole Life Insurance	Yourself Universal Life Insurance	Yourself Critical Illness	Yourself Disability Insurance
Your spouse/common-law	Your spouse/common-law Term Insurance	Your spouse/common-law Whole Life Insurance	Your spouse/common-law Universal Life Insurance	Your spouse/common-law Critical Illness	Your spouse/common-law Disability Insurance
Kid #1	Kid #1 Term Insurance	Kid #1 Whole Life Insurance	Kid #1 Universal Life Insurance	Kid #1 Critical Illness	Kid #1 Disability Insurance
Kid #2	Kid #2 Term Insurance	Kid #2 Whole Life Insurance	Kid #2 Universal Life Insurance	Kid #2 Critical Illness	Kid #2 Disability Insurance
Kid #3	Kid #3 Term Insurance	Kid #3 Whole Life Insurance	Kid #3 Universal Life Insurance	Kid #3 Critical Illness	Kid #3 Disability Insurance
Kid #4	Kid #4 Term Insurance	Kid #4 Whole Life Insurance	Kid #4 Universal Life Insurance	Kid #4 Critical Illness	Kid #4 Disability Insurance

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* 11. What about other financial products?

	RRSP	TFSA	RESP	Stocks	Mutual Funds	GIC	Commodities (Gold/Silver...)	Real Estate
Yourself	Yourself RRSP	Yourself TFSA	Yourself RESP	Yourself Stocks	Yourself Mutual Funds	Yourself GIC	Yourself Commodities (Gold/Silver...)	Yourself Real Estate
Your spouse/common-law	Your spouse/common-law RRSP	Your spouse/common-law TFSA	Your spouse/common-law RESP	Your spouse/common-law Stocks	Your spouse/common-law Mutual Funds	Your spouse/common-law GIC	Your spouse/common-law Commodities (Gold/Silver...)	Your spouse/common-law Real Estate
Kid #1	Kid #1 RRSP	Kid #1 TFSA	Kid #1 RESP	Kid #1 Stocks	Kid #1 Mutual Funds	Kid #1 GIC	Kid #1 Commodities (Gold/Silver...)	Kid #1 Real Estate
Kid #2	Kid #2 RRSP	Kid #2 TFSA	Kid #2 RESP	Kid #2 Stocks	Kid #2 Mutual Funds	Kid #2 GIC	Kid #2 Commodities (Gold/Silver...)	Kid #2 Real Estate
Kid #3	Kid #3 RRSP	Kid #3 TFSA	Kid #3 RESP	Kid #3 Stocks	Kid #3 Mutual Funds	Kid #3 GIC	Kid #3 Commodities (Gold/Silver...)	Kid #3 Real Estate
Kid #4	Kid #4 RRSP	Kid #4 TFSA	Kid #4 RESP	Kid #4 Stocks	Kid #4 Mutual Funds	Kid #4 GIC	Kid #4 Commodities (Gold/Silver...)	Kid #4 Real Estate

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* 12. When would you like to be contacted?

As soon as possible

This week

Next week

In 2-3 weeks

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* 13. How would you like to be contacted?

Email

Phone (during the day)

Phone (evening)

Phone (weekend)