ICA Annuity Quote Request

Annuity Quote Request
Thank you for the opportunity to support you and your client! The more details you provide, the better we can customize your solution. Once complete, click Submit—your information will remain confidential and be sent directly to our team.
Advisor Name*

First NameLast Name
Advisor Email Address*
example@example.com
Advisor Phone Number

Area CodePhone Number
Client Name*

First NameLast Name
Client DOB or Age*
Client Gender*

MaleFemale
Client Residence State*
State where application will be taken. (If different than residence state.)
Is this design going to be "Joint" or "Individual"?*

IndividualJoint
If Joint: Spouse/Partner's Name

First NameLast Name
Spouse/Partner's DOB
Approximate amount of investment:*
Will funds come from a qualified or non-qualified account?*

QualifiedNon-qualifiedI don't know
What type of account are the funds currently invested?

IRAROTH401(k)403bBrokerage accountAnnuityOther
How are the funds currently invested?

Mutual FundsETFsIndividual StocksIndividual BondsCD/Cash EquivalentOther
Will the funds come from another annuity?

YesNo
If yes, are there surrender charges? Please include details like surrender charge, remaining schedule, etc.
Income needs from annuity:*

NoneNowLaterInterest onlyNone
If this is Joint, Will joint income be needed?

YesNo
If applicable, what is the age the client will take income?
What type of products/compensation do you prefer?*

"I prefer products that pay a commission.""I prefer 'fee-only options."
What type of products/solutions do you prefer

Fixed Index Annuity (FIA)Multi Year Guaranteed Annuity (MYGA)Immediate Annuity (SPIA)Fee-Only Variable AnnuityI don't know
Do you have a preferred carrier(s)?
All Fixed and Fixed Index Annuities we offer provide tax deferral and principal protection. Please select other features that would be attractive to you: *

Competitive return to other safe investmentsCompetitive returns linked to the Stock IndicesGuaranteed income for life- singleGuaranteed income for life- jointImpairment, ADL, or LTC Feature RiderLeaving a legacy
When are you meeting with your clients?*

MonthDayYear
Date
(Optional)- Did you know we have a comprehensive offering? Please check the ideas that you would be open to learning more about.

Business Protection Solutions: E/O and Cyber InsuranceFamily ProtectionLong-Term Care PlanningLegacy PlanningBusiness Owner PlanningPolicy ReviewBack-Office Services (Growth, marketing, strategic planning)
Notes/Additional Information
ICA Insurance Services are administered by Lockton Affinity, LLC d/b/a Lockton Affinity Insurance Brokers LLC in California #0795478. Coverage is subject to actual policy terms and conditions. Policy benefits are the sole responsibility of the issuing insurance company.
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