• Annuity Suitability & Application

    All suitability will be reviewed by the Underwriting Dept. All information is be subject to verification and approval.
  • Application Intake Date:*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Agent Disclosure Section

    TO BE COMPLETED BY WRITING AGENT
  • Format: (000) 000-0000.
  • Annuity Owner Type*

  • Primary Annuitant Owner Information

    Please type in ALL CAPS
  • Format: (000) 000-0000.
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Marital Status*
  • Are you a US citizen?
  • ID Expiration Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Employment Type*

  • Joint Annuitant Owner Information

    Please type in ALL CAPS
  • Format: (000) 000-0000.
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Marital Status*
  • ID Expiration Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Employment Type*

  • Beneficiaries

    If additional space is needed, please use comment box below.
  • Primary Beneficiary Information
    Rows
  • Contingent Beneficiary Information
    Rows

  • Financial Information

  • Source of Income(s)

  • Child Support: How many months & years left to receive? years() and month(s).

  • Alimony: How many months & years left to receive? years() and month(s).

  • Taxable Income Tax Bracket*
  • Debt/Liabilities
    Rows
  • Liquid Assets*
    Rows
  • Non-Liquid Assets*
    Rows
  • Do you have any existing life insurance or annuity?*
  • Existing Policy Information
    Rows

  • FOR AGENT TO COMPLETE

    All of the following information must be completed by the Writing Agent
  • Income Rider*
  • Qualified Account*
  • Will the applied contract replace any annuity or life insurance?*

  • Investment Experience & Objectives

    Mark ALL that apply
  • Risk Tolerance*
  • Investment Objectives:*
  • Investing Time Horizon:*
  • Liquidity Needs:*
  • Source of Funds (Choose ALL that apply)*
  • Employer Retirement Plan(s)
    Rows
  • Funding Payment Submitted via:*

  • For Direct Transfer/Rollover/1035 - Plan Administrator Company: . Account #: . Client or Carrier Initiated:      

  • Personal/Business - ACH/Wire: Account Name:      Account Type:      
    Bank Name: Account #: Routing #:   

  • How do you anticipate taking distributions from this annuity? (check all that apply)*
  • Should be Empty: