ANNUITY QUOTE REQUEST FORM

Upon completion, email this form to your representative.

AGENT CONTACT INFORMATION:

Rep. Name: Agency/Producer #:

Rep. Email: Phone:

CLIENT INFORMATION:

Client Name: Gender: M F DOB:

Joint Annuitant: Gender: M F DOB:

State of Issue: Tax Qualified: Qualified Non-Qualified

GOAL OF THE ANNUITY: Top Priority of the Annuity

Accumulation Stage (pre-retirees who are still saving for retirement)

Income Stage: Immediate Annuity (income now) Deferred Annuity (income later)

Wealth Transfer / Death Benefit (passing on wealth to heirs)

DEPOSIT TYPE:

Single Premium: Initial Deposit: $ Additional Deposits, if any: $

Flexible Premium: Annual Amount: $ Monthly Amount: $

(deposit mode)

Source of Funds:

Direct Rollover / 1035 Amount: $ Savings Amount: $

Other Type: 401K 403B 457 CD Amount: $

For Agent Use Only – Not approved for use with the general public.

Page 1 of 2 AnnuityQuoteForm/Unbranded/9-14-20
 CLEAR FORM
ANNUITY QUOTE REQUEST FORM

MULTI-YEAR / FIXED / INDEXED ANNUITIES:

Insurance Company Preference, if any:

Preferred Surrender Period: Years

Income Rider Option: Yes No Defer Years / Starting Income Year

Income Frequency: Annual Monthly

SINGLE PREMIUM IMMEDIATE ANNUITY (SPIA):

Payout Option: Life Only Life w/ Certain Years

Joint 100% or 50%

Joint % w/ Certain Years

Installment Refund Cash Refund

Income Frequency: Annual Monthly

OTHER OPTIONS:

Principal Protection LTC

NOTES:

For Agent Use Only – Not approved for use with the general public.

Page 2 of 2 AnnuityQuoteForm/Unbranded/9-14-20