Annuity General Request Form

Please complete the following confidential request form to receive FREE information on Tax Deferred Annuity Investing. Please note: All fields must be completed.

  City:         State/Province: 
  Zip Code:   
  Home Phone:   
  Work Phone: 

  I'm most interested in learning more about:
  I consider myself a:
     Aggressive Investor    Moderate Investor   
     Conservative           Willing to accept NO risk  
  Do you currently own an annuity?           Yes   No
  Are you looking to upgrade this annuity?    Yes   No
  Are you a mutual fund investor?
     Yes   No
  Your age is:
     25-35    35-45    45-55    55-65   65-Above
  Your tax bracket is:
     28%    31%    36%    39.6%    Unknown
  Amount you may want to consider investing: 
     Single    Quarterly    Semi-Annually    Annually

  Your goal is:
     Tax Deferred Growth    Capital Preservation    Current Income   
  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.