Deferred Annuity Quote Request Form
SECTION I: APPLICANT INFORMATION
Applicant's Name:
Date of Birth:
Sex: Male
Female
SECTION II: QUOTE INFORMATION
State:
Amount of premium available:
The source this premium comes from:
(cash, IRA, 1035, CD)
Any surrender period requirements?
Will monthly income be needed? Yes
No
If yes, please specify:
How often would the income need to be paid? Annual    Semi-Annual
Quarterly    Monthly
These income payments would need to begin when?
When will funds be available for this case?
SECTION III: CASE INFORMATION
Are you in competition for this case? Yes
No
I don't know
If yes, please specify:
Any additional comments?