Name or Initials: Age  Status Single Married Partner Sibling Spouse/Other: Age

I am interested in : A, B, or C

A: Investment Annuity I currently have: (select all you have for source of funding) Annuity CD Money Market   401k IRA Savings Other Annuity Amount ($50,000-$5,000,000)

B: Income Annuity I currently have: (select all you have for source of funding) Annuity CD Money Market   401k IRA Savings Other Annuity Amount ($50,000-$5,000,000)

C: Annuity with Long Term Care Benefits I currently have: (select all you have for source of funding) Annuity CD Money Market   401k IRA Savings Other Annuity Amount ($50,000-$5,000,000) How much desired long term care rider amount : select one 50,000 75,000 100,000 125,000 150,000 175,000 200,000 I currently have a long term care insurance policy: Yes No

The reason I am requesting a quote.

Select One Curious about price. Need taxes deferred Want income now Want LTC Benefits Uninsurable/Declined for LTC

I have experience buying annuities and insurance by mail. Yes No

I will want free phone support when I apply. Yes No

When do you want to start?

select one ASAP this month 1-3 months 3-6 months

City and State of residence: (required - quotes are state specific)

E-mail me the quote to : (required to send quote)

(email address)

Phone: (entry required) *home, work, cell or repeat email
Best days to contact you:	M-F Sat Sun
Best times to contact you:	AM — PM

How did you find this website?

select one Google Ad Radio or TV Newspaper or magazine Bay Area Reporter Advocate Web Search Relative, friend, co-worker Link on a website AARP website or article

Are you an agent or licensed to sell annuities or insurance (active or inactive)? (required)