Annuity Quote Request

Client

Annuitant

* Name:

* E-mail Address:

* Address:

* Day Phone Number:

* Evening Phone Number:

* Birthdate:

* Sex:

Male     Female

Joint Annuitant

Name:

Birthdate:

Sex:

Male     Female

Annuity

Insurance Company Preference, if any:

 

State of Issue:

Tax Qualified:

Yes  No

Select One of the following annuity products:

Single Premium Deferred
                Single Premium Deposit $
Flexible Premium Deferred
                Annual Deposit $ or Monthly Deposit $
Single Premium Immediate
              Single Premium Deposit $ or Modal Benefit Desired $
                  Benefit Mode: Annual    Semi-Annual    Quarterly    Monthly
                  Date of Deposit:
                  Date of Initial Benefit:
Life Only   Life and Years Certain 
Year certain only/# of years: Installment Refund

Quote Impaired Risk SPIA?

Yes No

Describe Medical Conditions

Additional Information:

Please list any additional comments or competition information that will assist us in properly preparing your quote: