Annuity Quote Request

Advisor Name*

Client Name*

Date of Birth*

State*

Premium $*

Cost Basis $ (If Known)*

Tax Status*

Qualified

Non-Qualified

Inherited

Income Deferral Period (Years)*

Increasing or Level Income*

Increasing

Level

Single or Joint Income*

Single

Joint

Joint Name (if joint income)

Joint Date of Birth (if joint income)

Request IRR Report

Surrender Charge Period (Years)*

Product Type*

MYGA

FIA

Notes

Address

Email

Phone

Social

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Core Income Advisors

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