Annuity Quote Request Broker Information Agent Name *required Address City, State, Zip Code Email Address *required Business Phone *required Cell Phone Fax Radio Buttons Fax Mail Agent Pick-Up E-mail End Section Client Information Annuitant Name Birthday Sex Male Female Joint Annuitant Name Birthday Sex Male Female End Section 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 Flexible Premium Deferred Single Premium Immediate Premium Deposit $ Annual Deposit $ Monthly Deposit $ Single Premium Deposit $ Modal Benefit Desired $ End Section Plan Details Benefit Mode Annual Semi-Annual Quarterly Monthly Date of Deposit Date of Initial Benefit Type Please enter "Life Only Years Certain" or "Life and # Years Certain" or "Year Certain Only/ # of Years" or "Installment Refund" or "Cash Refund" Additional Information Please list any additional comments or competition information that will assist us in properly preparing your quote. End Section
