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Home
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Immediate Annuity
Immediate Annuity
Request an Immediate Annuity Quote
Broker Information
Name
*
First
Last
Company Name:
Phone
*
Fax
Email
*
Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Annuitant / Client Information
Name
*
First
Last
Birthdate
*
MM slash DD slash YYYY
Gender
*
Male
Female
Annuity Information
State of Policy Issue
*
Select One:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Type of Quote Requested:
*
Lump Sum Deposit
Solve for Specified Modal Amount
If Lump Sum, Amount of Deposit
*
If 'Specified Modal Benefit', state requested benefit amount to solve for:
How Is Benefit To Be Paid?
*
Choose One
Monthly
Quarterly
Semi-Annually
Annually
Requested Pay Out Option?
*
Select...
Life Only
Life 10 yr's cc
Life 15 yr's cc
Life 20 yr's cc
Joint Survivor 100%
Joint Survivor 75%
Joint Survivor 66 2/3%
Joint Survivor 50%
Joint & Cont. 100%
Joint & Cont. 75%
Joint & Cont. 66 2/3%
Joint & Cont. 50%
Other (give details in Remarks)
Survivors DOB (MM/DD/YYYY):
MM slash DD slash YYYY
(if requesting survivor benefit)
Survivor's Gender:
Male
Female
(if requesting survivor benefit)
Are these Funds Tax Qualified?
*
Yes
No
(retirement plan assets)
Are proceeds from a structured settlement:
*
Yes
No
(give details in remarks)
Date Of Deposit (MM/DD/YYYY):
*
Month
Day
Year
Date of First Benefit Payment?(MM/DD/YYYY):
*
Month
Day
Year
(must be at least 30 days from date of deposit)
Any Health Problems?
(for age rated S.P.I.A. with higher pay out)
Any Additional Remarks, Plan Design Requests, Specific Companies to Quote, etc.?
How would you like to receive the requested information?
*
Email
Fax
Pick-Up
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