First Name

Last Name

Street Address

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. 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

Day Phone

Evening Phone

E-mail Address

Best time to call:

8 - 10 a.m. 10 a.m. - 12 p.m. 12 - 2 p.m. 2 - 4 p.m. 4 - 6 p.m. After 6 p.m. Weekends  

Who is this quote for?

Me Spouse Parent Child Partner Business Assoc. Other  

Gender

Male Female  

Birthday (mm/dd/yy)

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 19

Your tax bracket:

15% 28% 31% 36% 39.6% other  

Amount of money you
want to invest: (note $5,000 is a typical minimum)

$

If this is not a lump sum investment,
how much do you plan to add to
the annuity?

$

How often will you deposit
additional funds?

Monthly Quarterly Semi-annually Annually  

If any funds are coming from a
Tax Qualified account, what
type of account is it?
(leave blank if irrelevant)

None IRA SEP-IRA Pension/Profit-Sharing 403b Annuity Deferred Comp  

If any funds are coming from a
Non-Tax Qualified account, what
type of account is it?
(leave blank if irrelevant)

None CD Savings Account Mutual Fund  

If funds are coming from
a CD, what month does it come due?

Not From CD Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec  

Primary consideration influencing
annuity purchase:

Tax-deferral Company offering annuity Interest rate offered Retirement planning Safety of principal  

Other consideration influencing
annuity purchase:

Tax-deferral Company offering annuity Interest rate offered Retirement planning Safety of principal  

How long would you like your
annuity to grow before
receiving income payments?

1 Year 5 Years 10 Years 10+ Years To Age 65  

Would you like an additional quote for any of the following insurance products?

 Life Insurance
 Disability Insurance
 Long Term Care Insurance
 Health Insurance
 Group Health Insurance
 Auto Insurance
 Homeowners Insurance
 Home Loans