(Our forms are state specific where necessary)

 

Agency Name Here

A few lines of text describing your agency

 

Agency Street Address

Agency City, Zip State

Agency toll free Phone (if applicable)

Agency Phone

Agency Fax

Agency E-mail:info@YourAgency.com

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Our agency is licensed to quote and write insurance policies only in State(s) you solicit & write policies. To find agents offering these coverages in all other states, please click the IQ.net logo.

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Annuity Quote

Completely fill out and submit this form to our agency to receive an accurate quote. You MUST provide at least one method of contact to receive a quote from our agency.

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Name (required)
E-Mail Address (required)
Street
City, State, Zip
Daytime Phone
Night Phone
FAX

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Investment Information

 

Amount of money you want to invest:

Is this a lump sum investment no yes

If 'NO' how much do you plan to add to the annuity:

How often will you deposit additional funds: Monthly Quarterly Semi Annual Annual

 

Are any funds coming from a Tax Qualified Account ? no yes

If 'YES' what type of account? IRA SEP-IRA Pension/Profit Sharing 403b Annuity Deferred Comp

 

Are any funds coming from a Non Tax Qualified Account ? no yes

If 'YES' what type of account? CD Savings Account Mutual Funds

Month CD comes due? Jan Feb March April May June July Aug Sept Oct Nov Dec