Quote Requests

Client Information

* Indicates required field

Name of Annuitant *

First

Last

Name of Joint Annuitant *

First

Last

Date of Birth *

Gender *

U.S. Resident? *

Yes No

U.S. Citizen? *

Yes No

Resident Country (if not U.S.) *

Coverage Details

Type of Annuity Requested *

Qualified (Pre-tax) Non-qualified (After-tax)

Single Premium Deferred

Deposit Amount *

1035 Funds *

Yes No

Multi-year Guarantee

Number of Years *

Maximum Surrender Charge Period (# of Years) *

Indexed

Indexed Maximum Surrender Charge (# of Years) *

Bonus *

Yes No

Single Premium Immediate

Deposit Amount *

1035 Funds *

Yes No

Agent Information

Agent *

Phone *

Email *

Agency *

City *

State *

Submit

Name of Insured *

First

Last

Date of Birth *

Gender *

Height *

Weight *

State *

Tobacco Use *

Yes No

If yes, date last used. *

Type of Tobacco Used *

Occupation/Industry *

Responsibilities/Duties *

Annual Income *

U.S. Resident? *

Yes No

U.S. Citizen? *

Yes No

Resident Country (if not U.S.) *

Monthly Benefit $ *

Existing Coverage $ *

Max Benefit *

Yes

Existing Coverage Type *

Individual Group

Elimination Period # of Days *

Benefit Period # of Years *

Business Overhead Coverage $ *

Has client ever been declined or rated for insurance? *

Yes No

If declined or rated, please provide details, including company. *

Date Last Consulted *

Reason for Visit *

Current Medications *

Diagnosis *

Other Details & Concerns *

Agent *

Phone *

Email *

Agency *

City *

State *

Submit

QUOTE REQUESTS

Annuity Quote Request

Client Information

Coverage Details

Agent Information

Disability Insurance Quote Request

Client Information

Coverage Details

Medical Provider

Health Questions

General Questions

Agent Information

Life Insurance Quote Request

Client Information

Coverage Details

Health Questions

General Questions

Agent Information

Long-term Care Quote Request

Client Information

Coverage Details

Medical Provider

Health Questions

Agent Information

Short-term Care Quote Request

Client Information

Coverage Details

Medical Provider

Health Questions

Agent Information

Connect

Products

Resources

QUOTE REQUESTS

Annuity Quote Request

Client Information

Coverage Details

Agent Information

Disability Insurance Quote Request

Client Information

Coverage Details

Medical Provider

Health Questions

General Questions

Agent Information

Life Insurance Quote Request

​Client Information

Coverage Details

Health Questions

General Questions

​Agent Information

Long-term Care Quote Request

Client Information

Coverage Details

Medical Provider

Health Questions

Agent Information

Short-term Care Quote Request

Client Information

Coverage Details

Medical Provider

Health Questions

Agent Information

Connect

Products

Resources

Client Information

Agent Information