Annuity Request Form

If you would like a no-obligation consultation to receive a quote to determine if an annuity is appropriate for your client(s), please take a few moments to complete the information on the request form below. After completed, click “send” at the bottom and we will be back in touch with you shortly.

This site employs strictly confidential email. Your name and information will not be shared with any mailing lists.

Advisor Name (required)

Your Email (required)

Phone Number

Client Name

Client Date of Birth

State of Residence


Marital Status

Premium Amount

Tax qualification

If you know the carrier or product you prefer, please list below

Where are the funds currently located?

Who will the beneficiaries be?

Are there any other important considerations?

Please hit "send" below and your request will be submitted. We will be in touch with you shortly. Thank you.

Call (800) 732-1489 or email for questions or issues with this form.