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

  I'm most interested in learning more about:
    Variable AnnuitiesEquity-Linked AnnuitiesFixed AnnuitiesImmediate AnnuitiesUnsureSelect One
    
  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:
    NoneLowMediumHighVery High 

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

  Additional Comments/Questions: