Client Data Form

– Business Insurance

What this Document is About

This document, called a Client Data Form
(CDEF), collects your financial and personal
information to help us provide you with advice.

Prepared for (client details)

Client name(s)

Date

Prepared by (Adviser details)

Adviser name

Company name
The above mentioned adviser is an authorised representative of The Complete Planner
Pty Ltd

Street address Phone number

Fax number

Email address

Postal address Website

Licensee details
The Complete Planner Pty Ltd ABN 48 077 994 104 AFSL Licence No. 278161
PO Box 856, Mt. Waverley, Vic. 3149
Phone: (03) 9882 2102 Email: [email protected] Website: www.thecompleteplanner.com.au

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 Client Data Form – Business Insurance

Please attach current copies of balance sheet, profit and loss statement and cash flow statements

1.0 Pre-Discovery
1.1 What is your reason for seeking advice?
For example, the scope of advice may include a review of the businesses’ existing insurances

Notes

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 Client Data Form – Business Insurance

2.0 Business Details

2.1 Contact Details
Business name

Australian Business Number (ABN)

Tax File Number (TFN)

Business Address

Street

Suburb

State

Postcode

Postal Address (Please tick if same as above)

Street

Suburb

State

Postcode

Phone, Fax and Email

Business phone

Business fax

Mobile

Email

Preferred contact method

Facebook Twitter LinkedIn

Social networking
Skype:

Additional details:

2.2 Authorised Officer(s) Details

Full name(s)

Position

Business phone

Email

Additional details:

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 Client Data Form – Business Insurance

2.3 Business Structure

Private Company Partnership Unit Trust Public Company
Business Structure
Family Trust Service Trust

Insert diagram of business structure/ownership:

Nature of business

Year business purchased/started

Full-time: Part-time:
Number of employees
Casual: Other:

Number of proprietors

Additional details:

2.4 Principal(s), Director(s) or Key Person(s) Details

Date Business Date Purchase
Name Key Person Responsibilities
of Birth Interest Acquired Amount

Yes No % $

Yes No % $

Yes No % $

Yes No % $

Yes No % $

Additional details e.g. income, duties etc.:

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 Client Data Form – Business Insurance

3.0 Current Position Analysis

3.1 Business Financials
Annual business gross turnover/net profit $

Annual business gross expenditure $

Surplus/(Deficit) $

Business loans/debts $

Business overdraft $

Estimate of business value $

Date of estimate

Business owner Accountant Solicitor

Provided by
Adviser

Methodology

Do you have a buy/sell arrangement and

Yes No n/a
supporting agreements?
Additional details:

3.2 Anticipated Major Capital Receipts and Anticipated Major Capital Expenses
Details Amount Owner When/Frequency

Total $

Additional details:

Notes

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 Client Data Form – Business Insurance

4.0 Existing Business Insurance Policies

4.1 Existing Insurance Policies
Do you have any existing insurance policies i.e. Life, TPD or Trauma? If yes, list below in 4.2 Yes No

4.2 Insurance Details including Life, TPD, Trauma and Business Expenses
Please provide details of existing insurance policies or rider benefits

Policy 1 Policy 2 Policy 3 Policy 4 Policy 5

Insurance type

Purpose e.g. key person

Date of commencement

Sum insured $ $ $ $ $

Policy number

Insurer

Policy owner

Insured name

Waiting period (if applic.)

Benefit period (if applic.)

Premium amount $ $ $ $ $

Premium type

Options/Benefits

Loadings/Exclusions

Additional details:

4.3 Preferences

Please list any insurers you would not

consider for new insurance

Additional details:

Notes

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 Client Data Form – Business Insurance

5.0 General Health Details

Insured person

Poor Poor Poor Poor

Fair Fair Fair Fair

What is your current health? Good Good Good Good

Very good Very good Very good Very good

Excellent Excellent Excellent Excellent

What is your height?

What is your weight?

Have you smoked cigarettes in the last

twelve months? Yes No Yes No Yes No Yes No
Are you presently or do you intend to
receive medical treatment for any
Yes No Yes No Yes No Yes No
medical issue?

If yes, please provide details

Have you been diagnosed with any

significant illness/illnesses in the last five
Yes No Yes No Yes No Yes No
years?

If yes, please provide details

Has any member of your immediate

family been diagnosed with any
Yes No Yes No Yes No Yes No
significant illness/illnesses?

If yes, please provide details

Do you play any sports or pursue outdoor

activities e.g. scuba diving, motor racing,
Yes No Yes No Yes No Yes No
football etc.?
Additional details:

6.0 Business Insurance Needs Analysis

6.1 Buy/Sell Protection
Would you like an analysis of your buy/sell requirements? Yes n/a
No
Owner

Value of business interest $ $ $ $

Would you like to allow for CGT liability
associated with transfer of business
Yes No Yes No Yes No Yes No
interest?
Insurance payout required in event of:

Owner death
Yes No Yes No Yes No Yes No

Owner TPD
Yes No Yes No Yes No Yes No

Owner trauma
Yes No Yes No Yes No Yes No

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 Client Data Form – Business Insurance

6.2 Personal Guarantees

Would you like an analysis of your personal guarantee requirements? Yes n/a
No
Person providing guarantee

Lender

Amount guaranteed $ $ $ $

Insurance payout required in event of:

Guarantor death
Yes No Yes No Yes No Yes No

Guarantor TPD
Yes No Yes No Yes No Yes No

Guarantor trauma
Yes No Yes No Yes No Yes No

Additional details:

6.3 Key Person Cover | Revenue

Would you like an analysis of your key person revenue requirements? Yes n/a
No
Key person

Reason they are a key person

(a) Salary cost of replacement e.g. extra

cost to replace key person on short $ $ $ $
notice
(b) Period required (years)

(c) Subtotal (a x b) $ $ $ $
(d) Recruitment costs e.g. a one-off
expense associated with the use of a
$ $ $ $
recruitment firm/agency to replace the
select person – does not include salary
(e) Reduction in business turnover e.g. do
you want to protect against the revenue
$ $ $ $
impact of losing a key person e.g.
reduced sales?
(f) Period required (years)

(g) Subtotal (e x f) $ $ $ $

(h) Other $ $ $ $
(i) Sub-total key person revenue
$ $ $ $
required (c + d + g + h)
(j) Company tax (i x 30%) $ $ $ $

(k) Grand Total (i + j) $ $ $ $

Insurance payout required in event of:

Key person death

Yes No Yes No Yes No Yes No
Key person TPD
Yes No Yes No Yes No Yes No

Key person trauma

Yes No Yes No Yes No Yes No

Additional details:

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 Client Data Form – Business Insurance

6.4 Key Person Cover | Capital

Would you like an analysis of your key person capital requirements? Yes n /a
No
Key person

Reason they are a key person

(a) Reduction in business value e.g. do you

want to protect against the capital
$ $ $ $
impact of losing a key person e.g.
reduced goodwill
(b) Liabilities to be settled on the loss of a
key person e.g. creditors, overdrafts $ $ $ $
and business loans
Total key person capital required (a + b) $ $ $ $

Insurance payout required in event of:

Key person death

Yes No Yes No Yes No Yes No

Key person TPD

Yes No Yes No Yes No Yes No

Key person trauma

Yes No Yes No Yes No Yes No

Additional details e.g. stamp duty etc.:

6.5 Business Expense Insurance Needs

Do you require an analysis of your business expense needs? Yes No n/a

Waiting period 14 days 30 days 90 days

Please provide an estimate of the business expenses as an annual amount or attach the most recent profit and loss statement

Accounting fees $

Rent $

Property rates and taxes $

Lease costs $

Allowable salaries – Employees $

Other employee costs $

Telephone $

Electricity $

Gas/Heating/Water $

Cleaning $

Other: $

Total $

Additional details:

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 Client Data Form – Business Insurance

7.0 Needs and Objectives

For example, your needs and objectives may be to protect revenue in the event of a loss of a key person

Needs and Objectives Priority

8.0 Professional Advisers

Solicitor Accountant Other:

Company name

Contact name

Address

Telephone/Fax

Email

Authority to contact Yes No Yes No Yes No

Additional details:

9.0 Review Frequency

How often would you like to review your position?

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 Client Data Form – Business Insurance

10.0 Client Declaration

I/We hereby declare that:

▪ A Financial Services Guide (FSG) and Adviser Profile were provided to me/us and I/we have read and
understood both documents
▪ The information provided in this Client Data Form – Business Insurance is a true reflection of my/our personal
financial situation, needs and objectives. I/We am/are not aware of any other information that would be relevant
to the making of a recommendation by my/our adviser
▪ I/We understand that where I/we have not completed some of the sections within this Client Data Form –
Business Insurance, my/our adviser is obliged to warn us that his/her advice may be based on incomplete or
inaccurate information
▪ I/We give permission for my/our Tax File Number, as provided in section 2.1, to be retained on file by my/our
adviser
▪ I/We hereby give consent for this information to be shared with third parties, for the purposes of preparing
relevant advice documents.
▪ I/We give permission for this information to be retained and used for the preparation of my/our relevant advice
document and in relation to any investment which I/we hold or may hold and I/we understand that any advice
and/or financial planning recommendations will be based on the information supplied in this Client Data Form –
Business Insurance. I/We acknowledge, in accordance with the Electronic Transactions Act (1999), this Client
Data Form – Business Insurance may be electronically stored securely for record-keeping purposes by my/our
adviser
▪ I/We authorise my/our adviser to contact the financial product providers that currently manage the financial
products that I/we hold as listed in this Client Data Form – Business Insurance, or as otherwise notified to
my/our adviser, in order for my/our adviser to ascertain my/our financial circumstances.

10.1 Business Representative(s) Authorisation

Representative 1 Signature

Signature

Full name Date

Position (if applicable) Director/Owner Trustee Authorised Officer

Representative 2 Signature

Signature

Full name Date

Position (if applicable) Director/Owner Trustee Authorised Officer

Representative 3 Signature

Signature

Full name Date

Position (if applicable) Director/Owner Trustee Authorised Officer

Representative 4 Signature

Signature

Full name Date

Position (if applicable) Director/Owner Trustee Authorised Officer

11.0 Adviser Declaration

The information recorded in this Client Data Form was provided during a discussion held on

The FSG and Adviser Profile were provided to the above mentioned client(s) on

The version number of the FSG provided was

Authorised Representative’s Signature

Authorised Representative’s Number

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 Client Data Form – Business Insurance

Office Use Only – AML/CTF Checklist

Has the required identification from the client and/or beneficial owners been collected and
Yes No
maintained on file? (beneficial ownership is ownership of 25% or more

Has the source of wealth and/or funds to be invested been identified?

Yes No
(e.g. inheritance, sale of property)

Has the risk assessment form been completed? Yes No

Notes

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