Immediate Annuity Request Form

Please complete the following confidential request form to receive FREE information on Immediate Income Annuities. Please note: All fields must be completed.

  City:         State/Province: 
  Zip Code:   
  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:
  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:
  Are you a Financial Advisor? (RIA, stockbroker, insurance agent, fee planner):

  Additional Comments/Questions:


Copyright 1998 Fielder Financial Management, Ltd.
All Rights Reserved.

Securities offered through Fortune Financial Services, Inc. member FINRA, SIPC.  Fielder Financial Management, Ltd. not affiliated with Fortune Financial Services, Inc.  Mark Fielder, Financial Professional, CA. Insurance Lic. # 0690576.