Annuity Quotes

Broker Information

Broker Name:     

 
 Address:     
 City:    
 State:   
  Zip:  
 Phone #:  
   Fax #:  
 E-mail Address:   
 Return Method:   Fax  Mail  Agent Pick-Up 
   E-mail  
 
Client Information

Annuitant 
   

 
 Name:   
 Birthdate:   
 Sex:  Male  Female  
 
 Joint Annuitant 
 
 Name:   
 Birthdate:  
 Sex: Male  Female 
Annuity Information
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 $   

Plan Details: 

 
Benefit Mode:      Annual  Semi-Annual 
  Quarterly  Monthly  
Date of Deposit:   
 
Date of Initial Benefit:    
  Life Only Life and  Years Certain 
Year certain only/# of years:   
    Installment Refund Cash Refund
 Additional Information:
Please list any additional comments or competition information that will assist us in properly preparing your quote.