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Broker Information
Agent Name
*
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Last
Phone
*
Email
*
Client
Annuitant
Name
*
First
Last
Birthdate
*
MM slash DD slash YYYY
Gender
*
Male
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Joint Annuitant
Name
First
Last
Birthdate
MM slash DD slash YYYY
Gender
Male
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Annuity
Insurance Company Preference, if any
State of Issue
*
Tax Qualified
*
Yes
No
Annuity Type
*
Choose One
Deferred Annuity
Immediate Annuity
Additional Information
Please list any additional comments or competition information that will assist us in properly preparing your quote.