Limitless CPSS - Annuity

Who is your SMD?*

Would you like a copy of this CPSS? If so, please add your email:

example@example.com

Is this your first time submitting business as a Writing Agent with our Ops team?

Agents on case:*

Rows	Agent Legal 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 to client	Are you securities licensed?	Commission Option:	Did you notify your upline if its a hot state? (Hot states in dropdown)
Writing agent:
Split agent:

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

Products(s) you are setting up:*

Rows	Annuitant Name	Product Type	Company Name	Product Name	Premium Amount	Source of Funds
Product 1
Product 2
Product 3
Product 4

Annuitant Information:*

Rows	Annuitant #1	Annuitant #2
Full Name
Age
DOB
Gender
Phone number
Email Address
SSN
Marital Status
Address
Years at current address
Birth State
US Citizen?
Do you have any dependents? If yes, how many?

Annuitant Identification:*

Rows	Annuitant #1	Annuitant #2
Form of ID:
State of Issue:
ID Number:
Expiration Date:

Joint Owner/Owner Different than Annuitant?*

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

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

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

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

Employment Information:*

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

Beneficiary Information (Annuitant #1):*

Rows	Name	DOB	SSN	Address	%	Relationship to Annuitant	If a Trust: Date Established, Trustee, Legal Name of Trust, Tax ID #
Primary Beneficiary #1
Primary Beneficiary #2
Primary Beneficiary #3
Contingent Beneficiary #1
Contingent Beneficiary #2
Contingent Beneficiary #3

Beneficiary Information (Annuitant #2):

Rows	Name	DOB	SSN	Address	%	Relationship to Annuitant	If a Trust: Date Established, Trustee, Legal Name of Trust, Tax ID #
Primary Beneficiary #1
Primary Beneficiary #2
Primary Beneficiary #3
Contingent Beneficiary #1
Contingent Beneficiary #2
Contingent Beneficiary #3

Current Insurance/Annuities (if applicable):

Rows	Select One	Carrier	Type	Coverage Amount	Year Purchased	Monthly Premium	Policy Number	Replacement
Account 1
Account 2
Account 3
Account 4

Suitability Questions/LIQUID Holdings:*

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

Suitability Questions/NON-LIQUID Holdings:*

Rows	Balance	Notes:
Annuities out of Surrender Term
Annuities in Surrender
Cash Value of Life Insurance
IRA
Real Estate Equity
401K
403(b)/457(b) Mutual Funds
TSP

Total Assets: Liquid/Investable assets & Non-Liquid Assets must match Rightbridge report.*

Rows	Please Enter Dollar Amount	Notes
Liquid/Investable Assets
Non Liquid Assets
Total Assets

Agent Questionnaire:*

Rows	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:*

Rows	Total Household Debt (excluding mortgage)	Total Household Monthly GROSS Income	Total Household Monthly Expenses
Owner/Annuitant

Household Income:*

Rows	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:*

Rows	Advantages of purchasing this product	Disadvantages of purchasing the proposed annuity?	Suitability Analysis: Describe how the current recommendation is suitable for the client.
Owner/Annuitant 1
Owner/Annuitant 2

Additional Notes:

Illustration*

Statement(s)*

Rightbridge Annuity Wizard*

Agent Acknowledgement: I affirm that I have completed this CPSS form in its entirety. I understand that any missing or incomplete information may cause delays in submission. I will also review my LICENSE & APPOINTMENT report in myWFG to ensure that I am properly licensed and appointed in the applicable state, along with the split agent.*

I agree