Annuity Request





Annuity Type


Broker Information

Broker Name*
Address
City
State
Zip
Phone*
Fax
Email*
Return Method
EmailFaxMailPick-up

Client

Annuitant Name*
Date of Birth*
Gender*
MaleFemale
Joint Annuitant Name
Date of Birth
Gender
MaleFemale

Annuity

Insurance Company Preference, if any
State of Issue
Tax Qualified
YesNo

Select One of the Following Annuity Products

Single Premium Deferred
Single Premium Deposit
Flexible Premium Deferred
Annual Deposit
Single Premium Immediate
Single Premium Deposit
or Modal Benefit Desired
Linked Benefit (LTC Combo)
Single Premium Deposit
or Monthly Premium Deposit
or Modal Benefit Desired
Benefit Mode

Date of Deposit
Date of Initial Benefit

Life Only
Life and
years certain
Years Certain Only
years
Installment Refund
Quote Impaired Risk SPIA?
YesNo
Describe Medical Conditions
Additional Information: Please list any additional comments or competition information that will assist us in properly preparing your quote
Your request cannot be honored unless this form is completed

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