Annuity Quote Request
Agent/Advisor Information
Agent/Advisor Name
*
First Name
Last Name
E-Mail
*
Phone Number
*
Agent/Advisor State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Annuitant Information
Joint Annuitants
*
Yes
No
Name
*
First Name
Last Name
Gender
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Additional Annuitant
Name
First Name
Last Name
Gender
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Financial Profile
Annual Gross income (combine for joint annuitants)
$0 - 50,000
$50,000 - 100,000
$100,000 - 150,000
$150,000 - 200,000
$200,000 - 300,000
$300,000 - 400,000
$400,000 - 500,000
$500,000+
Source of Income (check all that apply)
*
Salary
Investements
401(K)
Pension Plans
Other
Estimated Net Worth (exclude tangible assets)
$0 - 100,000
$100,000 - 250,000
$250,000 - 500,000
$500,000 - 750,000
$750,000 - 900,000
$900,000 - 1,200,000
$1,200,000 - 4,000,000
$4,000,000+
Current Savings and Investments (liquid net worth) *
$0 - 100,000
$100,000 - 300,000
$300,000 - 500,000
$500,000 - 1,000,000
$1,000,000+
What type of investments and insurance products do they own?
*
Mutual Funds
Stocks
Bonds
CD's
Savings Accouts
Life Insurance
Other Annuities
What is the purpose of this annuity?
Income
Accumulation
Safety of Principal
Other
Are they considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating an existing life insurance policy or annuity contract OR using monies from existing life insurance policies or annuity contracts to contribute to the new contract? *
Yes
No
How long has the policy or contract been in force?
What is the surrender charge?
Plan Design
Issuing State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Premium Amount
*
Can have multiple entries
Years of Deferral
*
1 - 10
Death Benefit
*
Yes
No
Confinement / LTC
*
Yes
No
Types of Funds
Qualified
Non-Qualified (Cash/Savings)
Premium Type
Flexible
Single
At least A Rated
Yes
No
Case Specific Information
Fixed Annuity (FA)
Fixed Indexed Annuity (FIA)
Multi-Year Guaranteed Annuity (MYGA)
Immediate Income
Variable Annuity (VA)
Preferred Carriers
Present With Business Builder?
Yes
No
Business Builder is a new software where it puts annuity ledgers side by side, up to 3 at a time.
Any Additional Information?
Submit
For Questions Please call 317-663-0061
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