Immediate Annuity Quote Request Form
SECTION I: ANNUITANT INFORMATION
Annuitant's Name:
Annuitant's Date of Birth:
Annuitant's Sex: Male
Female
JOINT ANNUITANT INFORMATION
Joint Annuitant's Name:
Joint Annuitant's Date of Birth:
Joint Annuitant's Sex: Male
Female
SECTION II: QUOTE INFORMATION
State:
Amount of premium available:
Is the premium Qualified Non-Qualified
How often will the income need to be paid? Annual
Semi-Annual
Quarterly
Monthly
These income payments would need to begin when?
Choose the payout method
(use the control key to select multiple choices)
Years certain(X from above):
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?