Agent Info:

    Name:      

    Agency:     

    Address:    

    City:               State:      Zip:      

    Phone #:         Fax #:

    E-mail address: 

General Information:

    Clients Name:     DOB:  

    Sex:   Male Female      Issue state:      Smoker:   Yes No

    Annuity Amount:      Qualified Money:   Yes No

    Period Certain:  5 10 15 20 Lifetime Other   Other:  

    Survivorship:   Single Joint

    If Joint Second Persons Name:  

    Second Persons Sex:   Male Female    Is the Second Person a Smoker:   Yes No

    Comments:  

For Medical Impairments, please complete the SPIA Underwriting Form to see if your client qualifies for the Underwritten SPIA