Hey there team twa!

Let's get your Annuity business submitted.

Annuitant *

Date of Birth (Annuitant) *

Social Security/ Tax ID Number (Annuitant) *

Marital Status *

IDENTIFICATION

ID Number , Include Issuing Government Agency

Phone *

Email *

Address

Street Address

City

State

Country

Postal code

Owner information, if different from above

Owner Name Here
Owner Date of Birth
Owner SSN/TIN
Identification (Agency, Number, Expiration)
Phone Number
Email
Relatioship to Annuitant

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (XXX) XXX-XXXX for assistance. You can reply STOP to unsubscribe at any time.

List Beneficiaries

Beneficiary 1, Name, DOB, and Percentage

Beneficiary 2, Name, DOB, and Percentage

Beneficiary 3, Name, DOB, and Percentage

Beneficiary 4, Name, DOB, and Percentage

For any additional, list in the detailed case notes section.

Plan Type and Premium

Qualified or Non-Qualified *

Plan Type *

Type of Funding *

Annuity Term *

Strategy *

Estimated Annuity Premium *

Additional Premiums (if applicable)

Monthly
Quarterly
Bi-Annual
Annual

HOUSEHOLD INFORMATION

To your knowledge will this annuity be in part or in whole a replacement of any existing annuities? *

Assets *

Liquid Checking/Savings
Non Qualified Investments/Brokerage
Qualified Investments/Brokerage

Liabilities *

Short Term Combined
Long Term Combined

List your Household Expenses *

Monthly Expenses not including Mortgage or Rent
Monthly Mortgage/Rent

Funding Source *

Annuity Detailed Case Notes *

Sourcing Agent/ Associate

Upline Agent

Writing Agent