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Annuity Quote Request Form

* Broker Name:
*Address:
*City:
*State: *Zip:
*Phone #: *Fax #:
*E-mail Address:
*Return Method: E-mail Fax   Mail   Re-Order  
Client

Annuitant
*Name:
*Birthdate:
*Sex: Male    Female

Joint Annuitant (if applicable)
Name:
Birthdate:
Sex: Male    Female

Annuity
Insurance Company Preference if any:
*State of Issue:
*Tax Qualified: Yes No If No, Cost Base

*Select One of the following annuity products:

Single Premium Immediate
Single Premium Deposit $ or Modal Benefit Desired $

Single Premium Deferred    Single Premium Deposit $

Re-Order

*Benefit Mode:   Monthly   Quarterly Semi-Annual Annual  

Income Payment Option:
Date of Deposit:
Date of Initial Benefit:
Life Only   Life and Years Certain  J/S
Year certain only/# of years: Installment Refund
J/S and Years Certain 
Quote Impaired Risk SPIA?
Yes, full APS is required : Call Us at 800.927.7732 No

Additional Information:
Please list any additional comments or competition information that will assist us in properly preparing your quote. MOST IMPORTANT: Ratings, Payout, Comp, etc.?

Your request cannot be honored unless this form is completed.