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Annuity Quote Request

Broker

1. Name
2. Phone
3. Email

Client

1. Annuitant
2. Name
3. Birthday
4. Gender

   Male Female
5. Joint Annuitant
6. Name
7. Birthday
8. Gender

   Male Female

Annuity

1. Insurance Company Preference, if any
2. State of Issue -- Select -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
3. Tax Qualified

   Yes No
4. Annuity Type -- Select -- Immediate Annuity Deferred Annuity
5. Immediate Annuity Details
6. Single Premium Immediate Single Premium Deposit or Modal Benefit Desired
7. Benefit Mode

   Annual Semi-Annual Quarterly Monthly
8. Date of Deposit
9. Date of Initial Benefit
10. Choose at least one option

    Life Only Life and Years Certain Year certain only/# of years: Installment Refund Cash Refund
11. Deferred Annuity Details
12. Choose One Option

    Single Premium Deferred
    Single Premium Deposit $ Flexible Premium Deferred
    Annual Deposit $
    or Monthly Deposit $ Multi-Year Guarantee
    Single Premium Deposit $
    Years of Surrender Charge: 1 2 3 4 5 6 7 8 9 10
13. Additional Information
14. Please list any additional comments or competition information that will assist us in properly preparing your quote:

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