Illustration Request
Agent Information
Agent Name
*
First Name
Last Name
Agent Email Address
*
example@example.com
Agent Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Product Type
*
Please Select
Fixed Indexed Annuity
Fixed Annuity / MYGA
Life Insurance
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Fixed Indexed Annuity Questions
Client Information
Primary Client's Name
*
First Name
Last Name
Suffix
Primary Client's Date of Birth
*
Please Select
Exact Date
Age
Primary Client's Date of Birth
*
-
Month
-
Day
Year
Date
Primary Client's Age
*
Client's State
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
Zip Code
Ownership Type & Qualification
Ownership Type
*
Please Select
Qualified (Pre-Tax Retirement Funds)
Non-Qualified (After-Tax Funds)
Non-Qualified Options
*
Please Select
Individual
Joint (Complete spouse details below)
Trust (Complete trust details below)
Spouse's Name
*
First Name
Last Name
Suffix
Spouse's Date of Birth
*
Please Select
Exact Date
Age
Spouse's Date of Birth
*
-
Month
-
Day
Year
Date
Spouse's Age
*
Name of Trust
*
Client Goals & Income Preferences
What is your Client's goal?
Largest Possible Lifetime Income Stream
Highest Fixed Rate
Guaranteed Minimum Growth
Highest Illustrated Growth
Specific Carrier
Specific Index
Planned Retirement Age
*
Already Retired
0-3 Years
4-7 Years
8-10 Years
10+ Years
When does the Client plan to start taking income FROM THIS PRODUCT?
*
Immediate Income
0-3 Years
4-7 Years
8-10 Years
10+ Years
Never
Other
Other
*
Please Select
Specify Age
Custom Income Plan
Specify Age
*
Custom Income Plan
*
Premium and Funding Details
Dollar Amount of Premium
*
Preferred Carrier
*
Preferred Rating
Please Select
AA
A
BBB
BB
None Specified
Is the Client willing to Pay a Fee for Added Growth or Income Potential?
*
Yes
No
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Fixed Index Annuities
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Fixed Annuity / MYGA Questions
Client Information
Primary Client's Name
*
First Name
Last Name
Suffix
Primary Client's Date of Birth
*
Please Select
Exact Date
Age
Primary Client's Date of Birth
*
-
Month
-
Day
Year
Date
Primary Client's Age
*
Client's State
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
State
Zip Code
Ownership Type & Qualification
Ownership Type
*
Please Select
Qualified (Pre-Tax Retirement Funds)
Non-Qualified (After-Tax Funds)
Non-Qualified Options
*
Please Select
Individual
Joint (Complete spouse details below)
Trust (Complete trust details below)
Spouse's Name
*
First Name
Last Name
Suffix
Spouse's Date of Birth
*
Please Select
Exact Date
Age
Spouse's Date of Birth
*
-
Month
-
Day
Year
Date
Spouse's Age
*
Name of Trust
*
Client Goals & Income Preferences
What is your Client's goal?
*
Largest Possible Lifetime Income Stream
Highest Fixed Rate
Guaranteed Minimum Growth
Planned Retirement Age
*
Already Retired
0-3 Years
4-7 Years
8-10 Years
10+ Years
When does the Client plan to start taking income FROM THIS PRODUCT?
*
Immediate Income
0-3 Years
4-7 Years
8-10 Years
10+ Years
Never
Other
Other
*
Please Select
Specify Age
Custom Income Plan
Specify Age
*
Custom Income Plan
*
Annuity Type & Customization
Type of Annuity Requested
*
Please Select
MYGA (Multi-Year Guaranteed Annuity) - Fixed Rate Growth
SPIA (Single Premium Immediate Annuity) - Immediate Income
DIA (Deferred Income Annuity - Future Guaranteed Income
Other
Other
*
Term Length
*
Please Select
3 Years
4-5 Years
6-7 Years
8-10 Years
Other
Other
*
Payout Structure
*
Please Select
Life Only (Max Lifetime Income, No Beneficiary Payout)
Life with Period Certain (Guaranteed Payout for X Years, Then Lifetime Income)
Joint Life (Income Continues for Spouse if Primary Passes Away)
Other
Specify Terms (Years)
*
Spouse's Date of Birth
*
Please Select
Exact Date
Age
Spouse's Date of Birth
*
-
Month
-
Day
Year
Date
Spouse's Age
*
Other
*
Premium & Funding Details
Premium Amount (Initial Deposit for Annuity Purchase
*
Will Additional Contributions Be Made?
Yes
No, One-Time Premium Only
Additional Riders & Features
Additional Features Requested (If Available for Selected Product)
Inflation Adjustment (Cost-of-Living Increase on Payments)
Return of Premium (Guarantees Refund of Initial Deposit to Beneficiaries)
LTC / Nursing Home Waiver (Waives Surrender Fees if Confined to a Facility)
Communtation Feature (Allows Partial Withdrawal While Maintaining Income Stream)
Other
Other
Final Acknowledgement & Preferences
Preferred Carrier(s)
*
Comparison of Multiple Options
*
Yes
No
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Fixed Annuity / MYGA
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Life Insurance Questions
Client Information
Client's Name
*
First Name
Last Name
Suffix
Client's Date of Birth
*
Please Select
Exact Date
Age
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Client's Age
*
Gender
*
Male
Female
Prefer Not to Say
Client's State
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
State
Zip Code
Underwriting & Health Information
Weight and Height
*
General Health Classification
*
Standard
Preferred
Rated
Smoker Status
*
Please Select
Non-Smoker
Smoker / Tobacco User
Type
*
Cigarettes
Cigar
Vape
Marijuana
Any Significant Medical Conditions?
No
Yes
Significant Medical Conditions
*
Medications Currently Taken
Has the Client Been Declined or Rated for Life Insurance Before?
No
Yes
Please Explain
*
Any Family History of Serious Illness (Heart Disease, Cancer, etc.) Before Age 60?
No
Yes
Coverage Details
Type of Life Insurance Needed
*
Term Life
Permanent Life
Specialized Life Insurance
Term Length
*
5 Years
10 Years
15 Years
20 Years
30 Years
Other
Other
*
Permanent Life
*
Whole Life Insurance (Fixed Premiums, cash value accumulation, lifelong coverage)
Universal Life (UL) (Flexible premiums, interest-based cash value growth)
Indexed UL (IUL) (Stock market index-based growth, downside protection)
Final Expense Insurance (Small whole life policy for funeral & burial costs)
Specialized Life Insurance
*
Guaranteed Issue (No medical exam, ideal for high-risk applicants)
Simplified Issue (Health questions but no medical exam required)
Survivorship (Second-to-Die) (Pays out after both insured individuals pass away)
Credit Life (Mortgage or Loan Protection) (Pays off debt upon insured's death)
Purpose of Coverage
*
Income Replacement
Mortgage Protection
Final Expense
Estate Planning (Estate tax liguidity, wealth transfer)
Business Protection (Key Person, Buy-Sell Agreement)
Charitable Giving
Other
Business Name
Business Structure
Sole Proprietor
LLC
S-Corp
C-Corp
Partnership
Other
Other Business Structure
*
Other
*
Solve for Death Benefit of Premium
*
Death Benefit
Premium
Desired Coverage Amount
*
Specified
Minimum Non-MEC
Maximize Cash Accumulation
Specified Amount
*
Premium Budget
Per
Month
Year
Illustration Type
*
Lowest Cost
Balanced Cost / Benefit
Max Cash Value Growth
Payment Mode Preference
Monthly
Quarterly
Annually
Single Pay
Limited Pay (10-Pay, 20-Pay, etc.)
Policy Customization
Cash Value & Growth Preferences
*
Maximum Growth Potential
Conservative Growth Potential
Guaranteed Growth
Living Benefits (Accelerated Benefits of Chronic / Terminal Illness, LTC, etc.)
No
Yes
Additional Riders & Features Requested
Waiver of Premium
Accidental Death Benefit
Child / Spouse Rider
Guaranteed Insurability
Return of Premium
Other
Other
*
Final Acknowledgement & Preferences
Preferred Carrier(s)
*
Comparison of Multiple Options
*
Yes
No
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Additional Notes
Any Additional Notes or Special Requests for This Illustration?
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