Annuitant Information:
Name:    Male  Female
D.O.B.  Age:   State:

Joint Annuitant Information (if any):
Name:     Male   Female
D.O.B:  Age:   State: 

Source of Funds:
Non- Qualified (cash, 1035 exchange so on)
Qualified (Ira, 401K rollover, Pension so on)

Deposit Amount: $
Desired Income: $
1035 Cost Basis  $

Deposit Date: Month -- 01 02 03 04 05 06 07 08 09 10 11 12 Day -- 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 Year 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030

Income Start: Month -- 01 02 03 04 05 06 07 08 09 10 11 12 Day -- 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 Year -- 2031 2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 --

Annuity Payment Frequency:
Monthly Semi-Annually Quarterly Annually

Type of Immediate Annuity:
SINGLE LIFE
Life Only
Life With period certain of:
      5 Year 10 Years 15 Years 20 Years 
      Specific: 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 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 and   0 1 2 3 4 5 6 7 8 9 10 11 Months
Life With Installment Refund 
Life With Cash Refund (low availability / none joint lives)

Joint LIFE
Joint & Survivor Lives ONLY
Joint With period certain of:
    5 Year 10 Years 15 Years 20 Years   
    Specific: Years 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 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 and   0 1 2 3 4 5 6 7 8 9 10 11 Months
Joint Percent To Survivor 100% 75% 66.6 50% 33.3% 25%

Period Certain ONLY
  Period Certain Only for:
5 Year 10 Years 15 Years 20 Years
Specific:   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 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Years and 0 1 2 3 4 5 6 7 8 9 10 11 Months

Annual Inflation COLA: -- 1% 2% 3% 4% 5% CPI-U

Agent Email: required
Phone: Appreciated
Fax: If you would like quotes faxed
Signing Agent:
Requested by: (If other than agent)

Receive quote BY:
Email Adobe Acrobat PDF   Email Text
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Poor health client? Should try an impaired risk quote. (Brochure PDF)

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