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

Broker Information