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Immediate Annuity Quote Request Form
Guaranteed retirement income for life! Please fill in as much information as possible.
 Agents Must Click Here

Annuitant Information:
Name:   
Male  Female
D.O.B.  Age:   State:

Joint Annuitant Information (if any):
Name:    
Male   Female
D.O.B:  Age:   State: 

Source of Funds:
 Non- Qualified (cash, 1035 exchange etc.)
Qualified (Ira, 401K rollover, Pension etc.)

Deposit Amount: $
Desired Income: $
1035 Cost Basis  $

Deposit Date: Month Day Year

Income Start: Month Day Year

Annuity Payment Frequency:
Monthly Semi-Annually Quarterly Annually

Type of Immediate Annuity:
SINGLE LIFE
Life Only
Life With period certain of:
      5 Year 10 Years 15 Years 20 Years 
      Other: Years and   Months
 Life With Installment Refund 
Life With Cash Refund (low availability / none joint lives)

Joint LIFE
Joint & Survivor Lives ONLY
Joint With period certain of:
    5 Year 10 Years 15 Years 20 Years   
    Other: Years and   Months
Joint Percent To Survivor

Period Certain ONLY
   Period Certain Only for:
5 Year 10 Years 15 Years 20 Years
 Other:   Years and Months

Annual Inflation COLA:

Email: required
Phone: Appreciated
Fax: If you would like quotes faxed
Requested By:

Receive quotes by:
Email Adobe Acrobat PDF   Email Text
Fax Phone Call

Please use the comment for any special requests that do not appear on the form.
Comments - Requests - Referred By:

 

 

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Last modified: 10/18/06