Quote Request: Immediate Annuity

Preferred Name / Nickname

Date of Birth (MM/DD/YYYY) *

Are you a U.S. Citizen? *

Yes No Unknown Unanswered

Immigration Status *

Permanent Resident/Green Card Holder Visa Holder

Country of Birth *

Date of Entry *

Visa/Green Card Type *

Visa/Green Card Expiration Date *

Preferred Contact Number *

Email Address *

Address

Address 2 (Apt, Suite, etc...)

City *

Zip Code

Household Information

Marital Status *

Number of Children *

Ages of Children

Immediate Annuity Options

Primary Annuitant's Gender *

Male Female

Tax Status of Annuity: *

Qualified Non-Qualified

Cost basis, if known:

Select One: *

Single Premium Deposit Desired Benefit Amount

Insurance companies limit 50% of investable assets to be used to purchase an Immediate annuity – please confirm that the below Single Premium Deposit dollar amount represents less than 50% of the Proposed Annuitant’s investable assets.

Payments: *

Monthly Quarterly Semi-Annually Annually

Life with Installment Refund *

Yes No

Life with Cash Refund *

Yes No

Life with Period Certain *

Yes No

How many years? *

An Immediate Annuity with the Lifetime Contingencies can be suitable for a person who is in excellent health, who wants guaranteed income and who has no issues that would prevent them from living a long and healthy life. If an annuitant has been treated for heart disease, cancer, kidney disease or has other chronic health issues, an Immediate Annuity may not be suitable. Please confirm that there is no known history of or diagnosis of any disease or disorder that would limit the annuitant(s) longevity. *

I confirm that I'm in good health I've had some health issues

Period Certain / Specified Years Only *

Yes No

How many years? *

First Payment from Contract Date: *

30 Days In One (1) Year Other

If customization is required, please specify:

Please note: Immediate annuity quotes are valid for two weeks only. Are you planning to implement the immediate annuity strategy in the next two weeks? *

Yes No

Date Quote Needed By *

Send Quote To *

Myself & Copy Advisor Advisor Only

Additional Details

Additional details you'd like to include to help us with the quote.