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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