Client Information Sheet - Annuities

Enter Client Details

First Name *

Last Name *

Date of birth

MM-DD-YYYY

Place of Birth

Height

Weight

Social Security Number

Gender

ID/Driver License Number

ID/Driver License Number Expiration Date

Address

Street Address

City

State

Country

Postal code

Years at Current Address

Phone *

Email *

Marital Status

U.S Citizen?

State of Birth

How long have you been in the USA?

Finances

Taxable Accounts

Savings
Checking
CDs
Mutual Funds
Stocks
Bonds
Treasuries

Taxable Account Notes

Total Taxable Amount

$

Tax Deferred Accounts

IRAs
401(k), 403(b) and other pension assets
Fixed Annuities
Variable Annuities
Saving Bonds
Others

Tax Deferred Account Notes

Total Tax Deferred Amount

$

Tax Advantage Accounts

Roth IRA
Cash Value Life Ins.
529 Plan or College
Savings Programs

Tax Advantage Account Notes

Total Tax Advantage Amount

$

Other Life Insurance Policies

Other Life Insurance Policies Notes

Employment Information

Are you currently employed?

Employer Name

Position

Previous Employer Name

Previous Occupation

Type of Business/Industry

How Long at Current Job?

Employer's Full Address

Annual Income

$

Net Worth

$

Doctor Information

Primary Doctor Name or Clinic Name

Primary Doctor's Phone Number

Doctor's Full Address

Last Doctor Visit

Reasons/Results of Last Visit

Beneficiaries

Will the beneficiary be an individual or a trust?

Full Trust Name

Established Trust Date

MM-DD-YYYY

Trust Tax ID Number

Trustee Full Name

Trustee Date of Birth

MM-DD-YYYY

Trustee Social Security Number

Trustee Full Address

Beneficiary Full Name #1

Beneficiary Relationship #1

Beneficiary Date of Birth #1

MM-DD-YYYY

Beneficiary Percentage #1

in %

Primary or Contingent - Beneficiary #1

Beneficiary Full Name #2

Beneficiary Relationship #2

Beneficiary Date of Birth #2

MM-DD-YYYY

Beneficiary Percentage #2

in %

Primary or Contingent - Beneficiary #2

Beneficiary Full Name #3

Beneficiary Relationship #3

Beneficiary Date of Birth #3

MM-DD-YYYY

Beneficiary Percentage #3

in %

Primary or Contingent - Beneficiary #3

Additional Beneficiary Section

Banking Information

Check here to use a one-time automatic debit from the owner's checking or savings to fund this application.

Bank Name

Name on Account

Bank Account Number

Bank Routing Number

Preferred Draft Date (1st – 28th)

Agent Information

Writing Agent Full Name

Split Agent Full Name

Policy Notes:

Upload clear copy of an ID, Passport, Visa or ITIN Letter

Upload up to 4 files

PDF, DOCX, DOC, JPEG, JPG or PNG ( max 4 Files )

Attach Client Illustrations for Processing

Up to 3 Illustrations

PDF, JPEG, JPG, PNG, DOCX or DOC

Upload a clear copy of your Trust Certificate

Upload up to 4 files

PDF, DOCX, DOC, JPEG, JPG or PNG ( max 4 Files )