IMMEDIATE ANNUITY QUOTE REQUEST FORM

Annuitant Information:
Name:
Male  Female
DOB:   Age:   State:

Joint Annuitant Information (if any):
Name:
Male  Female
DOB:   Age:   State:

Deposit Amount: $
Desired Income: $

Source of Funds:
 Non-Qualified (cash, 1035 exchange, etc.)
     Cost Basis: $
Qualified (Ira, 401k rollover, pension, etc.)

Deposit Date:  Month Day Year

Income Start:  Month Day Year

Annuity Payment Frequency:
Monthly  Semi-Annually  Quarterly  Annually

Type of Immediate Annuity:

SINGLE LIFE
Life Only
Life With period certain of:
        5 Years  10 Years  15 Years  20 Years
        Other  Years and Months
 Life With Installment Refund
Life With Cash Refund (low availability / none joint lives)

JOINT LIVES
Joint & Survivor Lives ONLY
Joint With period certain of:
        5 Years  10 Years  15 Years  20 Years
        Other  Years and Months
Joint Percent to Survivor %

Period Certain ONLY
Period Certain Only for:
        5 Years  10 Years  15 Years  20 Years
        Other  Years and Months

Poor Health?  Should try an impaired risk quote.

Annual Inflation COLA: %

CONTACT INFORMATION

Email: required
Name:
Phone: appreciated
Fax: if you would like quotes faxed

Receive quotes by:
 Email Adobe Acrobat PDF  Email Text
Fax  Phone Call

Please use the comments for any special requests that do not appear on the form:
Comments - Requests - Referred By: