Broker Broker First Name *

Broker Last Name *

Phone *

Email *

Client / Annuitant First Name *

Last Name *

Birthdate *

Gender * MaleFemale

Joint Annuitant First Name *

Last Name *

Second Applicant Date of Birth *

Gender MaleFemale

Annuity Insurance Company Preference, if any

State of Issue * Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Amount *

Tax Qualified * YesNo

Annuity Type * Select Deferred Annuity Immediate Annuity

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