Name:         
  Address:    
  City:         State/Province: 
  Zip Code:   
  Email:      
  Home Phone:   
  Work Phone: 


  Do you currently own an annuity? 
     Yes   No
  
  Are you looking to "convert" an existing annuity to an Immediate Annuity? 
     Yes   No
  
  Is this part of a 'structured settlement'?
     Yes   No
    
  Your age is:   Your Spouse's age (if applicable): 
    
  Amount you may want to consider investing: 
      Single Deposit Only

  Type of pay out option desired:
    Life IncomePeriod Certain (years [5,10,15,20])Period Certain & Life (years [5,10,15,20])Unsure, I need guidance!
  
  Your estimated time frame to purchase an annuity plan is:
     Less than one month    1 to 3 months    3 to 6 months

  Your general awareness on this subject is:
    NoneLowMediumHighVery High 

  Are you a Financial Advisor? (RIA, stockbroker, insurance agent, fee planner):
    NoYes 

  Additional Comments/Questions: