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Please complete the following information:* Indicates a required fieldBroker Information:Broker Name: *Phone: *Fax: *Email: *Address: *City: *State: *Zip: * Requested return method: * Fax Email Mail Client Information:Annuitant Name: *Date of Birth: * (mm/dd/yy) or Age: Sex: * Male Female Joint Annuitant Name:Date of Birth:Sex: Male FemaleState of Issue*: Tax Qualified: YES NO Product Information:Select one of the following Annuity Products:Single Premium Deferred Single Premium Deposit: Maximum Surrender Period: (Years) Flexible Premium Deferred Annual Deposit: or Monthly Deposit: Single Premium Immediate (select one) Single Premium Deposit: or Modal Benefit Desired: Benefit Mode: Annual Semi-Annual Quarterly Monthly Date of Deposit: Date of Initial Benefit: Benefit Information:(check all that apply)Life Only Life and Years Certain Year Certain Only for # yrs: Installment Refund Additional Comments:
Requested return method: * Fax Email Mail