Annuity Request Form

Fill in the form below to receive an Annuity Product Quote.

Client:
Annuitant
Name
Birth Date
Sex	Male Female
Joint Annuitant
Name
Birth Date
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
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.
Originator I.D.