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Annuity Proposal Request
Bank Name
Referred By
Date		5/9/2008 7:03:08 PM
Client Information
Name
Best Time to Call			AM			PM
Phone	Home				Work				Cell
Address
City					State				Zip
Date of Birth
SPIA
Premium							q		nq
Benefit
Payout Mode				monthly			quarterly
				semi-ann.			annual
Cost Basis
Purchase Date
1st Payout Date
Company(-ies)
Deferred
Premium							q		nq
Accumulated Goal						At Age
Withdrawals							interest only			10% annually
Beginning in year
Guar. Period
Company(ies)/ Product(s)
Settlement Option Information
			Life Only (Primary Annuitant)
			Period Certain Only
per. cert.					Yrs		mos.
			Life with Period Certain
per. cert.					Yrs		mos.
			Joint Lives Only
%surv.						100		75		66.67
						50	other
			Joint Lives with Period Certain
per. cert.					Yrs		mos.
%surv.						100		75		66.67
						50	other
			Refund Option
Illustrator's Use Only
Illustrator
Date			5/9/2008 7:03:08 PM
Notes