Variable Annuity Quote Request

Please complete the following information if you would like to obtain a Variable Annuity quote. Please understand this form is not an application. We will first contact you with a quote, then an application and prospectus will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

What is your name?

Last

First

Middle

What is your e-mail address?

e-mail

What state do you reside in?

State

What is your tax bracket?

Tax Rate

What is your telephone number?

Telephone

What is your fax number?

Fax

What is your birth date?

Birth Date

What is your gender?

Gender

 Male Female

When do you plan to retire?

Anticipated Retirement Age
(example 65)

Interest in this Annuity?

Who is it for?

 Yourself
Relative
Friend
Employee

Is the money being deposited Qualified Funds?

(Are you bringing them over from an IRA, SEP, Keogh, Pension, or 401(k)?

 Yes No
 

Terms

What terms would you prefer
for your quote?

A monthly income that pays out for the lifetime of the annuitant, no matter how long the annuitant lives

This will generate the maximum monthly payout.


A monthly income that pays out for the lifetime of the annuitant, and at least 10 years certain no matter how long the annuitant lives.

This will generate less than the maximum monthly payout.

A monthly income that pays out for the lifetime of the annuitant, and at least 20 years certain no matter how long the annuitant lives.

This will generate even less then the plan above.

To request a quote, make one selection, fill in the amount for that selection, then click on the submit button. For additional quotes, repeat the procedure.
 

Annuity Quote based on an amount deposited

Single Premium Immediate Annuity

Monthly payments starting in 30 days from now

 Lump Sum Deposit

Variable Annuity

Monthly payments starting at the anticipated
retirement age

 Make a:
Lump Sum Deposit (one)
OR
Monthly Deposits
(continuing until retirement age)

Amount of one Deposit:
 

Quote based on monthly income needed

Desired Monthly Income

Amount

Variable Annuity

Lump Sum Deposit required for desired monthly income to start at the anticipated retirement age.

Monthly Deposit required for desired monthly income to start at the anticipated retirement age.
 

Best Time to Contact You

Please let us know the best time to call and discuss your quote.

Morning
Afternoon
Evening
Anytime
Or specify other:
 
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