Annuity Quote Request Form

General Info

Advisor Name(Required)

Today's Date(Required)

Date Needed(Required)

Client Name(Required)

First Last

Male/Female(Required)

Male

Female

Date of Birth(Required)

State(Required)

Qualified or Non Qualified(Required)

Qualified

Non Qualified

Single or Joint(Required)

Spouse Name

First Last

Spouse's Date of Birth

Specific Carrier Rating?

Premium Amount or Solve for Particular Amount

FIA Quote/Illustration Accumulation Case

Any Particular Product(Required)

Index/Strategy(Required)

Withdrawals/RMDs(Required)

Income Rider Case

Immediate Income/Years of Deferral(Required)

Qualified or Non Qualified(Required)

Qualified

Non Qualified

Enhanced Benefits (Doubler)

Specific Particular Product/Carrier?(Required)

Top Three Side-by-Side?(Required)

Best One?(Required)

Full Company Illustration(Required)

SPIA Quote

Life Only(Required)

Life w/ Period Certain(Required)

Life /w Cash Refund(Required)

Life /w Installment Refund(Required)

Period Certain Only(Required)

Joint Life(Required)

Joint Life /w Period Certain(Required)

Payment Mode (M,Q,S,A)(Required)

Cost Basis (if NQ$)(Required)

MYGA Rate Request

Specific Product/Carrier(Required)

Duration (2-10yrs)(Required)

Withdrawals Y/N(Required)

Interest Only?(Required)

Up to 10% What Percentage?(Required)

Income in the first year?(Required)

Notes/Comments