The Annuity Qualifier

Trying to determine the most suitable annuities for your needs? Answer a series of simple questions and our Annuity FYI Affiliates will help you determine if an annuity is suitable for you, and if so, the best type for your individual needs.

Learn more about our Annuity FYI Affiliates, including their qualifications.

*Asterisks denotes required field

Name:*
State:*	Select Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming (Not all annuities are available in all states; we need to know your state to evaluate your annuity against other products on the market.)
Email Address:*
Retype Email:*
Phone Number:*	- - (In the event that we need additional information prior to making a recommendation.)

Please enter information about your annuity to aid us in our evaluation. If you don't know an answer to a question, leave it blank.

When are you planning on purchasing an annuity:* Select Next 30 days In 30 to 60 days In the next 2-6 months More than 6 months from now Undecided (please elaborate):

How well do you understand annuities?: Select I have extensive knowledge I have some understanding I am fairly new to annuities

Owner, Annuitant, and Beneficiary Information: Who will be purchasing the annuity (this person is called the owner, and the person who retains investment control)? Owner’s year of birth: Owner’s state of residence: Select Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Annuity Information: Enter the approximate dollar amount that you are thinking of sheltering in an annuity:* Do you prefer an annuity that will invest in funds tied to stock market performance, understanding that there will be fluctuations in the value? Or would you prefer an annuity that has a competitive fixed interest rate that will not vary with the ups and downs of the stock market, thus protecting your principal? Select Fixed interest rate Variable rate Not sure Is it a priority that you have spur-the-moment access to withdraw your money without a fee? Select Yes No Not sure (please elaborate): How soon would you like to start receiving regular income from the annuity? Select Immediately (interest only) Immediately (interest and principle) 1-5 years 5-10 years At retirement (please elaborate) When you start receiving regular payments from the annuity, how much monthly income do you need the annuity to provide? Where do the funds used to purchase the annuity originate? Select 401k or pension account IRA TSA / 403(b) Existing annuity or life insurance policy Maturing CD Brokerage Account Sale of home or business Estate settlement Other (please elaborate) I am a financial professional / broker. Additional Comments:

Information submitted on this form, including e-mail addresses, is considered confidential and will not be shared with any other third parties.

Updated 09/10/2011