February 28, 2017

Annuity Quote Form

First Name (required) :     Last Name (required) :

Street Address (required) :     City (required) :     State (required):     Zip Code (required) :

Phone (required) :     Your Email (required) :     Best Time To Reach You:

Annuitant Information:

Annuitant's First Name     Annuitant's Last Name

Annuitant Date Of Birth   Month (required)     Day (required)     Year (required)

Annuitant's Gender   Is there a Joint Annuitant?

Joint Annuitant Information:

Joint Annuitant's First Name     Joint Annuitant's Last Name

Joint Annuitant Date Of Birth   Month     Day     Year     Joint Annuitant's Gender


Insurance Company Preference if any:     State of Issue:     Tax Qualified

Select One of the following Annuity Products:

Single-Premium-Deferred     Single Premium Deposit $

Flexible-Premium-Deferred                 Annual Deposit $   or Monthly Deposit $

Single-Premium-Intermediate   Single Premium Deposit $   or Modal Benefit Desired $

Benefit Payout Mode: monthlyquarterlysemi-annualannual

Date of Deposit:     Date of Initial Benefit:

Life OnlyLife and Years Certain   Year certain only / # of years: Installment Refund

Quote Impaired Risk SPIA ?

Describe Medical Conditions:

Additional Information:
Please list any additional comments or competition information that will assist us in properly preparing your quote.

Please contact us by phone if you'd prefer to speak to an agent or need help with this form. We can be reached at (916) 984-9320