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Annuity Quote Request

Fill in the form below to receive an Annuity Product Quote:

Fields marked with * are required

Annuity Quote Request Form:

* Broker Name:

*Address:

*City:

*State: *Zip:

Phone #: Fax #:

E-mail Address:

Return Method: Fax Mail Broker Pick-Up E-mail

Client:

Annuitant
*Name:

*Birthdate:

*Sex: Male Female

Joint Annuitant
Name:

Birthdate:

Sex: Male Female

Annuity:

Insurance Company Preference if any:

State of Issue:

Tax Qualified: Yes No

Select One of the following annuity products:

Single Premium Deferred Single Premium Deposit $

Flexible Premium Deferred

Annual Deposit $ or Monthly Deposit $

Single Premium Immediate

Single Premium Deposit $ or

Modal Benefit Desired $

Benefit Mode: Annual Semi-Annual Quarterly Monthly

Date of Deposit:

Date of Initial Benefit:

Life Only Life and Years Certain

Year certain only/# of years: Installment Refund

Quote Impaired Risk SPIA? Yes No

Describe Medical Conditions

Additional Information:
Please list any additional comments or competition information that will assist us in properly preparing your quote.

Your request cannot be honored unless this form is completed.

StarLife Partners is currently licensed in the State of New York The StarLife Partners web site is maintained exclusively for active producers contracted with carriers through StarLife Partners, and is intended for agent use only. All information is intended for use as a guide, or as reference, and is believed to be current as of the date of its posting. Any misrepresentation of the information contained in the StarLife Partners web site by its users is strictly prohibited.

The list of registered StarLife Partners web site users is reviewed for business-related activity on a regular basis. Only registered users will
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