*  First Name

*  Last Name

*  Street Address

*  City

*  State

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*  Zip Code

*  What is Your Daytime Number?

*  What is Your Evening Number?

*  Best Time to Contact You:

8 - 10 a.m. 10 a.m. - 12 p.m. 12 - 2 p.m. 2 - 4 p.m. 4 - 6 p.m. After 6 p.m. Weekends

*  What is Your Email Address?

*  What is Your Gender

Male Female

*  Birthday (mm/dd/yy)

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 19

  * What Amount of Money
Would You Like to Invest?
($5,000 is a typical minimum)

$

 * What is Your tax bracket:

15% 28% 31% 36% 39.6% other

 * If this is not a lump sum investment,
how much do you plan to add to
the annuity?

$

 * How often will you deposit
additional funds?

Monthly Quarterly Semi-annually Annually

If any funds are coming from a
Tax Qualified account, what
type of account is it?
(leave blank if irrelevant)

None IRA SEP-IRA Pension/Profit-Sharing 403b Annuity Deferred Comp

If any funds are coming from a
Non-Tax Qualified account, what
type of account is it?
(leave blank if irrelevant)

None CD Savings Account Mutual Fund

 * If funds are coming from
a CD, what month does it come due?

Not From CD Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

 * Primary consideration influencing
annuity purchase:

Tax-deferral Company offering annuity Interest rate offered Retirement planning Safety of principal

 * Other consideration influencing
annuity purchase:

Tax-deferral Company offering annuity Interest rate offered Retirement planning Safety of principal

 * How long would you like your
annuity to grow before
receiving income payments?

1 Year 5 Years 10 Years 10+ Years To Age 65

Are You Interested in an additional quote?
Our Follow-up Forms Utilize the Information You've Already Input to Minimize Your Time.

 Annuities (Retirement Vehicle)
 Auto Insurance
 Disability Insurance
 Group Health Insurance
 Health Insurance
 Homeowners Insurance
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 Long Term Care Insurance

*  Required Fields