Personal data sheet

							        Welcome to Bernie Clayton Insurance and Accusure Business Services!
Date___________       Nature of visit? Please indicate below. Circle all that apply.

Personal ( page 1)           Business (pages 1 & 2)    Consultation       Insurance            Tax/bookkeeping

                                                Personal Data
Name__________________________________ Nickname___________________                             Sex______

Address_____________________________________City___________________Zip____________

DOB____________________              SS#_________________________ DL#___________________

Phone__________________________                 Work Phone _______________________Smoker_____

Fax # ___________________________               Email ____________________________________

Employer____________________________________________ Job Title__________________

Spouse Name______________________________              Nick Name_______________

Employer_________________________________              Work Phone__________________________

Fax #____________________________               Email_______________________________________

DOB__________________                SS# _____________________ DL#______________________

Children(s) Name________________________ DOB___________ Sex____ SS#______________

                  ________________________             ___________        ____         _______________

                  ________________________             ___________        ____         _______________

                  ________________________             ___________        ____         _______________

STOP HERE ***********************************************************************

Insurance:        Auto       Home/renters       Life   Health Disability               Long term care

                  Annuities          Other________________

Consultation      Business           Personal          Need(s)____________________________________

Tax Preparation 1040         941     UCT6       Other________________

Notes & Priorities:
        Welcome to Bernie Clayton Insurance and Accusure Business Services!
Date___________       Purpose of visit?                   Insurance        Tax/bookkeeping            Consult

                                                 Business Data
Business name:___________________________________ Operational or Start up Target Date_______

Sole prop.        Incorp. C S       Partnership           Limited Liab.    Non Profit        For Profit

Owner name(s) and title(s)________________________________________________________________

Address____________________________________ City___________ County____________ Zip______

Phone_______________________ Fax______________________ Email___________________________

Nature of operations_____________________________________________________________________

Federal Tax ID #________________________ State Tax ID #_________________________

Bank / Credit Union________________________________ Account #____________________________

Business ATM / Credit cards_____________________________________________________________
STOP HERE***************************************************************************

Number of Employees_______          Number related to Owner(s)________ Home business_____________

Leasing company_______________________                    Bookkeeper/accountant________________________

Entity Set up     Business plan     Grants       Zoning      Assoc. Membership(s)______________________

Facilities need   Office ________Sq. Ft.         Manufacturing _______Sq. Ft.      Assembly _______Sq. Ft.

CGL      Workers Comp      Prof. Liab.           Auto Ins.           Home Owners   Officers/Directors E&O

Health Ins.       Disability Ins.    Life Ins.            Buy Sell


Notes & Priorities: