Limitless CPSS - Annuity

Agents on case:*

	Agent Name:	Agent ID	% Split:	Current Promotion Level	NPN #:	Last 4 SSN:	Are you licensed/appointed?	Phone number/Email:	How long have you known them?	Relationship
Writing agent:
Split agent:

Product(s) you are recommending (Select all that apply):*

Products(s) you are setting up:*

Annuitant Information:*

Annuitant Identification:*

Joint Owner/Owner Different than Annuitant?*

Owner Information/Joint Owner (If different from Annuitant):

	Owner Information	Joint Information	Owner Information	Joint Information
Full Name
Gender
Age
DOB
SSN
Address
Phone number
Birth State
US Citizen?
If not a US Citizen, which Country?
Marital Status
Email Address:
Years at current address:
Policy this information is for:

Owners Identification/Joint Owner Identification (If different from Annuitant):

	Owner:	Joint Owner:	Owner:	Joint Owner:
Form of ID:
State of Issue:
ID Number:
Expiration Date:
Policy this information is for:

Employment Information:*

	Annuitant #1	Annuitant #2
Employer (If retired, state previous career/information)
Position
Address
Phone Number
Annual Income
Net worth

Beneficiary Information (Annuitant #1):*

Beneficiary Information (Annuitant #2):

Current Insurance/Annuities (if applicable):

Suitability Questions/LIQUID Holdings:*

	Balance	Year Est.	Notes:
Checkings/Savings
IRA
CD's
Mutual Funds
Stocks/Bonds
401K
Cash/Precious Metals
TSP
Annuities (Out of Surrender)
Money Market/Brokerage Account
403b/457b

Suitability Questions/NON-LIQUID Holdings:*

Agent Questionnaire:*

	Product Name:	What is your clients financial objective?	Number of years these funds will be invested	Annuity Tax type	For Qualified Option:	Funding Sources:
Account 1
Account 2
Account 3
Account 4

Is there an income rider? If yes, which rider?

Household Income:*

	Total Household Debt (excluding mortgage)	Total Household Monthly GROSS Income	Total Household Monthly Non-Discretionary Income
Owner/Annuitant

Household Income:*

	Do you anticipate any major financial changes during the surrender period of this product? Explain	Source of Income	What is the intended use of the annuity	Long term liabilities (e.g. Mortgage)	Short term liabilities (e.g. credit cards)
Owner/Annuitant 1
Owner/Annuitant 2

Rationale:*

	Advantages of purchasing this product	Disadvantages of purchasing the proposed annuity?	Suitability Analysis/The basis for my recommendation to purchase the proposed annuity or to replace or exchange your existing annuity (ies)?
Owner/Annuitant 1
Owner/Annuitant 2

Additional Notes:

Illustration*

Statement(s)*

Rightbridge Annuity Wizard*

FNA*