Agent First Name

Agent Last Name

Agent Email

Agent Phone

Client Name:

Date Of Birth:

State:—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Target Premium:

Spouse Name:

Spouse Date Of Birth:

Where is the money coming from:—Please choose an option—Traditional IRARoth IRA401KPensionInherited IRA403BTSA457 PlanSavings / CheckingSale of home / businessQualified AnnuityNon-qualified AnnuityMoney MarketNQ Brokerage Accountunknown

Is this account coming from an active employment sponsored plan?YESNO

Please select the following statement that best describes your clients primary goal:—Please choose an option—Client is interested in safe growth with best possible returnsClient is interested in immediate single lifetime incomeClient is interested in single lifetime income in 1-5 yearsClient is interested in single lifetime income in 6-10 yearsClient is interested in immediate joint lifetime incomeClient is interested in joint lifetime income in 1-5 yearsClient is interested in joint lifetime income in 6-10 yearsClient is interested in income replacement for their spouse onlyClient is interested in income replacement for themselves if their spouse passesClient is interested in leaving the most amount of money possible as a legacyClient is interested in single lifetime income in 11+ years

Currently taking money from this account? If so, how much?

If not taking money, at what age does the client anticipate taking withdrawls?

Additional Comments:

Attachment 1:

Attachment 2:

Attachment 3: