PWYB Annuity Intake Form

INTAKE FORM

All information is collected securely in this official PWYB Intake Form
Which Agent Are You Working With?

Annuitant Information

The Annuitant is the person that will collect the payments from the Annuity. This is not always the Owner.
Is the Owner going to be the Annuitant that collects the annuity payment(s)?*

YesNo
What is the relationship of the Owner to the Annuitant?
What is the relationship of the Secondary Owner to the Annuitant?
Annuitant Type
Individual Annuitant
Name

First NameLast Name
Suffix
Email
example@example.com
Phone Number
Please enter a valid phone number.
DOB

MonthDayYear
Date
Social Security Number
Gender

MaleFemale
Address same as Owner?

NoYes
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Trust Annuitant
Trust Name
Trust Type
Date of Trust Established

MonthDayYear
Date
SSN / ITIN
Trustees*

INTAKE FORM