| For Help Call 818-887-8585 |
|
| Fields marked (*) are mandatory. |
|
| Personal Information |
|
| Name | |
| Mainlnsured's Soc. Sec. # | |
| Address | |
| City | |
| State | |
| Zip | |
| Property Address (if different from above) | |
| City | |
| State | |
| Zip | |
| Day Phone | |
| Night Phone | |
| Best Time To Call | |
| Email Address | |
| Occupation | |
| Date of Birth | |
| Type of Current Account | |
| Current Account Balance | |
| Penalty for Moving? | |
| If yes, what % or $ amount | |
| Is an upfront bonus important? (could cover surrender charge or market losses) | |
| Federal Tax Status | |
| Your Investment Objective - Please List all that apply: Income now, Flexibility, Tax deferral, Growth followed by income, Growth-possible income, Pass on to beneficiaries, Guarantees, Other) | |
| With the exception of withdrawals (ie: required minimum distribution, systematic withdrawals of credits/interest, etc), how do you expect to take money out of this product? | |
| When do you expect to take money out of this account | |
| What is your source for this annuity’s premium | |