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Annuity Illustration Request Form
Date
MM slash DD slash YYYY
Broker Information
Broker Name:
Broker Phone:
Broker Email:
Client Information
Annuitant:
Gender
M / F
M
F
DOB:
Annuitant:
Gender
M / F
M
F
DOB:
Contract State:
SPIA
Premium:
Qualifed
Non-Qualified
Benefit:
Payout Mode:
monthly
quarterly
semi-annually
annually
Cost Basis:
Purchase Date:
MM slash DD slash YYYY
1st Payout Date:
MM slash DD slash YYYY
Company(s):
DEFFERRED
Premium:
Qualifed
Non-Qualified
or accumulated goal:
at age/year:
Withdrawals:
interest only
10% annually
Beginning in yr.:
Guarantee Period:
Company(-ies)/ 1)
Product(s) 2)
3)
Settlement Option Information
Life Only (Primary Annuitant):
Period Certain Only:
per.cert.
Years
Months
Life with Period Certain:
per.cert.
Years
Months
Joint Lives Only:
%Surv:
100
75
66.67
50
Other
Other
Joint Lives with Period Certain:
%Surv:
100
75
66.67
50
Other
per.cert.
Years
Months
Other:
Refund Option:
Installment Refund
Cash Refund
NOTES
Notes:
Δ
