Complete this
quick & easy Annuity request form and one of our
licensed insurance professionals will call you to review
your annuity investment options.
You may also call our agency direct at
800-685-572.
Your State:
City:
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Annuity Type:
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What is your investment objective?
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Dollar amount of your estimated initial
investment?
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What is your time frame for this investment?
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Where is this investment currently?
**
What is
the current rate of return you are receiving on these funds?
% If funds are not
currently invested, please state so in the box.
Will
you be making periodic investments to the above amount :
YesNo
If yes, enter amount and Frequency:
Will this Annuity replace or change existing
Annuities or Life Insurance?
Yes
No
If yes, please give reason for
replacement
Desired annual income to be generated by this investment:
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Who will this quote be for:
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Marital Status:
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First Name:
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Last Name:
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Contact Phone:
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Alt Phone:
E-mail:
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Best time to call:
Birth Date:
Month Day Year
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Sex:
Male Female
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Height & Weight:
(Pounds)
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Do You Smoke or use tobacco?:
Yes No
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Need Quotes within:
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Additional Information or Request:
Investments offered through Jefferson Pilot Securities
Corporation, Member SIPC to residents of CT 5 Forest Park
Drive, Farmington, CT 06032, Phone: 800 678-7806
