Personal Information

Name:
Address 1:
Address 2:
City, State, Zip:
Email Address:
Home Phone:
Work Phone:
Social Security#:
Date of Birth:
Spouse's Name:
Spouse's SS#:
Spouse's DOB:

Employment Information

Working:	Yes No
Employer Name:
Position:
Spouse Employer Name:
Spouse Position:
Primary Income:	Employment Investments Social Security Other
Tax Bracket:	15% 28% 31% 36%+
Combined Annual Income:	$0 - $22,750 $22,750 - $55,100 $55,100 - $115,000 $115,000+
Net Worth:	$0 - $50,000 $50,000 - $250,000 $250,000 - $599,000 $600,000+
Will proposed annuity REPLACE any annuity in force?	Yes: No:
If yes, give reason
If yes, surrender charges (if any) explained?	Yes: No:
Which best describes your investment risk tolerance?	Risk - Adverse Conservative Moderate Aggressive
Will these monies be needed in the next one to three years?	Yes: No:
Purpose of proposing annuity (check all that apply) Long Term Growth Reduce Income Taxes Retirement Savings Safety of Principal Non Qualified Savings Income for Customer Income for Surviving Spouse Other If Other, What?