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	Life Insurance

Annuity Proposal Request Form

Fields marked with an asterisk (*) are required.

Return Method:
	Fax Mail E-mail

Client

Annuitant:


*Birthdate:


*Sex:
	Male Female

*Client's state of residence:


State Where Application is to be signed (if different):



Joint Annuitant:


Birthdate:


Sex:
	Male Female


Owner (if different than Annuitant):


Birthdate:


Sex:
	Male Female

Owner's state of residence:


State Where Application is to be signed (if different):

Type of Annuity

We can provide quotes for the following products: Single Premium Immediate Deferred Multi-Year Guarantee Deferred Initial Rate Equity Indexed Annuity Please complete the appropriate section(s) below.

Single Premium Immediate

Single Premium Deposit:


Or Modal Benefit Amount Desired:


Benefit Mode:
	Annual Semi-annual Quarterly Monthly

Date of Deposit:


Date of Initial Benefit:


Tax Qualified:
	Yes No

Cost Basis if Non-Qualified:


Possible Impaired Risk Annuitant:
	Yes No

Benefit period(s) desired:
	Life Only Period Certain of: Cash Refund Life with Period Certain of: Installment Refund Joint and Survivor with % to survivor:
	Reduction effective on death of: Primary Secondary Either

Insurance Company Preference:

Deferred Annuity

Deposit Amount:


Subsequent Deposit Amount if Desired:


Tax Qualified:
	Yes No

Rate Guarantee Period:


Liquidity Options:
	Interest only 10%/year Systematic Withdrawal

Amount Required:


Insurance Company Preference:

Equity Indexed Annuity

Deposit Amount:


Subsequent Deposit Amount if Desired:


Tax Qualified:
	Yes No

Length of Contract:


Liquidity Options:
	Interest only 10%/year Systematic Withdrawal

Amount Required:


Insurance Company Preference:



Questions? Call (800) 837-5433: