Agent Name:

Agent Phone Number:

Agent Email:

Client Name:

Age:

Gender:
—Please choose an option—MaleFemale

State:—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Proposed Annuity Amount (Min: $5,000):

Spouse Name:

Spouse Age:

Where is the money coming from:
—Please choose an option—Traditional IRARoth IRA401KPensionInherited IRA403BTSA457 PlanSavings / CheckingSale of home / businessQualified AnnuityNon-qualified AnnuityMoney MarketNQ Brokerage AccountTSPLife Insuarnce

Is this account coming from an active employment sponsored plan?YESNO

Please select the following statement that best describes your clients primary goal:—Please choose an option—Client is interested in growth with best possible returnsClient is interested in immediate lifetime incomeClient is interested in lifetime income in 1-6 yearsClient is interested in lifetime income in 7-9 yearsClient is interested in lifetime income in 10+ yearsClient is interested in income replacement for their spouse onlyClient is interested in income replacement for themselves if their spouse passesClient is interested in leaving the most amount of money possible as a legacy

Is the client currently taking withdraws/income from this account? If so, how much?

If not taking withdraws/income at what age does the client anticipate taking withdraws/income? *If not planning on taking write "n/a"

Additional Comments:

Attachment 1:

Attachment 2:

Attachment 3: