Annuity Application Form
Contract Owner
By whom is the application made?
Individual
Corporate
Joint
Trustee
Corporation Name
Trustee Name
Date of Trust
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Joint Contract Owner
Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Annuitant
Annuitant is
Same as owner
Not an individual
Other
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Owner
Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Beneficiary Designation
Will you like to designate a beneficiary?
Yes
No
Beneficiary #1
Primary
Contingent
Percentage
If the primary beneficiary is a Trust or Corporation, please check the appropriate box:
Individual
Trustee
Corporation
If beneficiary is a Trust:
Revocable
Irrevocable
Name (First, Middle, Last or Trust/Corporate/Custodian Name)
First Name
Last Name
Date of Trust
-
Month
-
Day
Year
Date
Relationship to Owner
Beneficiary #2
Primary
Contingent
Percentage
If the primary beneficiary is a Trust or Corporation, please check the appropriate box:
Individual
Trustee
Corporation
If beneficiary is a Trust:
Revocable
Irrevocable
Relationship to Owner
Name (First, Middle, Last or Trust/Corporate/Custodian Name)
First Name
Last Name
Date of Trust
-
Month
-
Day
Year
Date
Back
Next
Type of Contract
Type of Contract
Qualified
Non Qualified
Qualified Options
Direct Transfer
Contribution for Tax
New Keogh Plan
Rollover (Within 60 day)
Rollover Options
IRA
Non-Deductible IRA (Roth)
Tax Year
Contribution for Tax Options
IRA
Non-Deductible IRA (Roth)
Non Qualified Options
Individual
Joint
Trust
Corporation
Transfer
Transfer Options
1034 (b) (9) (PR)
1035 (a) Exchange
Back
Next
Annuity Product Selection
Select Product
FIA (Index Annuity)
MYGA (Fixed Annuity)
Select FIA Term
5 Years
7 Years
FIA Premium Payment
Select from the Index (es) and/or the Fixed account choices and indicate the allocation percentage for each.
S&P 500®
MSCI® EAFE
MSCI® EM
Fixed Account
S&P 500 Allocation Percentage: (0, 25, 50, 75, 100
MSCI® EAFE Allocation Percentage: (0, 25, 50, 75, 100)
MSCI® EM: (0, 25, 50, 75, 100)
Fixed Account: (0, 25, 50, 75, 100)
Select MYGA Term
3 Years
5 Years
7 Years
10 Years
Premium Payment 3 YearsTerm
Premium Payment 5 YearsTerm
Premium Payment 7 YearsTerm
Premium Payment 10 YearsTerm
Back
Next
Replacement
Do you have existing life insurance or annuity contracts?
Yes
No
Will the annuity contract applied for replace or change existing contract or policies?
Yes
No
Amount
Agent Information
Agent Name
Agent Number
Agent Email
example@example.com
Agent Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: