Annuity Application Form

Annuity Application Form
Contract Owner
By whom is the application made?
IndividualCorporateJointTrustee
Corporation Name
Trustee Name
Date of Trust
MonthDayYear
Date
Name
First NameLast Name
Phone Number
Please enter a valid phone number.
Date of Birth
MonthDayYear
Date
Email
example@example.com
Residential Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code

Joint Contract Owner
Name
First NameLast Name
Email
example@example.com
Date of Birth
MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Residential Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code

Annuitant
Annuitant is
Same as ownerNot an individualOther
Name
First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Owner
Residential Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code

Beneficiary Designation
Will you like to designate a beneficiary?
YesNo
Beneficiary #1
PrimaryContingent
Percentage
If the primary beneficiary is a Trust or Corporation, please check the appropriate box:
IndividualTrusteeCorporation
If beneficiary is a Trust:
RevocableIrrevocable
Name (First, Middle, Last or Trust/Corporate/Custodian Name)
First NameLast Name
Date of Trust
MonthDayYear
Date
Relationship to Owner
Beneficiary #2
PrimaryContingent
Percentage
If the primary beneficiary is a Trust or Corporation, please check the appropriate box:
IndividualTrusteeCorporation
If beneficiary is a Trust:
RevocableIrrevocable
Relationship to Owner
Name (First, Middle, Last or Trust/Corporate/Custodian Name)
First NameLast Name
Date of Trust
MonthDayYear
Date

Type of Contract
Type of Contract
QualifiedNon Qualified
Qualified Options
Direct TransferContribution for TaxNew Keogh PlanRollover (Within 60 day)
Rollover Options
IRANon-Deductible IRA (Roth)
Tax Year
Contribution for Tax Options
IRANon-Deductible IRA (Roth)
Non Qualified Options
IndividualJointTrustCorporationTransfer
Transfer Options
1034 (b) (9) (PR)1035 (a) Exchange

Annuity Product Selection
Select Product
FIA (Index Annuity)MYGA (Fixed Annuity)
Select FIA Term
5 Years7 Years
FIA Premium Payment
Select from the Index (es) and/or the Fixed account choices and indicate the allocation percentage for each.
S&P 500MSCI EAFEMSCI EMFixed Account
S&P 500 Allocation Percentage: (0, 25, 50, 75, 100
MSCI EAFE Allocation Percentage: (0, 25, 50, 75, 100)
MSCI EM: (0, 25, 50, 75, 100)
Fixed Account: (0, 25, 50, 75, 100)
Select MYGA Term
3 Years5 Years7 Years10 Years
Premium Payment 3 YearsTerm
Premium Payment 5 YearsTerm
Premium Payment 7 YearsTerm
Premium Payment 10 YearsTerm

Replacement
Do you have existing life insurance or annuity contracts?
YesNo
Will the annuity contract applied for replace or change existing contract or policies?
YesNo
Amount
Agent Information
Agent Name
Agent Number
Agent Email
example@example.com
Agent Phone
Please enter a valid phone number.
Should be Empty: