SPIA QUOTE REQUEST FORM

About Yourself >
Broker First Name:
Broker Last Name:
E-mail Address:
Telephone:
Fax:
Annuitant Information >
1. Primary Annuitant:
Name:
Gender:
Date of Birth:
2. Second Annuitant:
Name:
Gender:
Date of Birth:
Quote Information >
3.   Type of SPIA:

4.  Health Status:
(Check if we should try an impaired risk Quote)
5.   Income Options:

6.   Length of Certain Period:
(If Applicable)

Years

Months
7.   Annual Inflation COLA:
8.   Solve For:
9.   Amount of Deposit or Income Desired: $
10. Tax Status: Qualified
Non-Qualified
11. Cost Basis:
(Required if exlusion ratio is requested)
12. Mode of Payment:

13. State:
(Where Application will be Signed)
14. Deposit Date:
(MM/DD/YYYY)
15. Start Date:
MM/DD/YYYY)
16. Additional Comments / Special Requests: