Annuity Quote Request

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

Fields marked with * are required

Annuity Quote Request Form:
* Broker Name:
*State: *Zip:
Phone #: Fax #:
E-mail Address:
Return Method: Fax   Mail   Broker Pick-Up   E-mail


*Sex: Male    Female

Joint Annuitant
Sex: Male    Female


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:
Date of Initial Benefit:
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.

Your request cannot be honored unless this form is completed.

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