Here's how simple it is to get started towards
your financial future...

Put a Professional to work for You...

Let us show you what we can do for you!  We are trained to take the mystery out of financial and estate planning.  Please understand this is not an application for insurance.  An application will be sent to you if coverage is desired.

(1) Fill in your contact and other related information below.
(2) Give us some brief information about you.
(3) Re-check your information to make sure it is correct.
(4) Click the submit button (just once), sit back and relax!

Please note items with * are necessary fields.
Personal Information  
Your Salutation (Mr. Mrs. Ms. Miss): First & Last Name:
 *
Address (1)
 *		 Address (2)
City:
 *		 State:
 *		 Zip
 *
Your e-mail:
 *		 please check your complete e-mail again
(AOL users please use complete address)
Daytime phone:
*  please check it twice		 Evening phone:
 *  please check it twice
  Tax Bracket Gender Birthdate
    Tax Rate Male   Female *
    (mm/dd/yy)
When do you plan to retire?
Anticipated retirement age:		 Interest in this Information:
Who is it for?

Yourself
Relative

Friend
Employee
Is the money being
deposited Qualified Funds?
(Are you bringing them over from an IRA, SEP, Keogh, Pension, or 401(k)?
       YesNo
Terms
What terms would you prefer for your quote? A monthly income that pays out for the lifetime of the annuitant, no matter how long the annuitant lives. This will generate the
maximum monthly payout.
A monthly income that pays out for the lifetime of the annuitant, and at least 10 years certain no matter how long the annuitant lives. This will generate less than the maximum monthly payout.
A monthly income that pays out for the lifetime of the annuitant, and at least 20 years certain no matter how long the annuitant lives. This will generate even
less then the plan above.

To request a quote, make one selection, fill in the amount for that selection, then
click on the submit button. For additional quotes, repeat the procedure.
Annuity Quote based on an amount deposited
Single Premium
Immediate Annuity		 Monthly payments starting in
30 days from now		     Lump Sum Deposit
  $ 
Deferred Annuity Monthly payments starting at
the anticipated retirement age		     Lump Sum Deposit (one)
            --- or ---
    Monthly Deposits
    (continuing until retirement age)
        Amount of one deposit
  $ 
Equity Indexed
Annuity		 Monthly payments starting at
the anticipated retirement age		     Lump Sum Deposit (one)
            --- or ---
    Monthly Deposits
    (continuing until retirement age)
        Amount of one deposit
  $ 
Quote based on monthly income needed
Desired Monthly Income

Amount:

  $ 
Single Premium
Immediate Annuity
Lump Sum Deposit
required for monthly income
starting in 30 days		  
Flexible Premium
Deferred Annuity
Lump Sum Deposit
required for desired monthly income to start at the anticipated retirement age.
Monthly Deposits
required for desired monthly income to start at the anticipated retirement age.
Equity Indexed
Annuity
Lump Sum Deposit
required for desired monthly income to start at the anticipated retirement age.
Monthly Deposits
required for desired monthly income to start at the anticipated retirement age.
Best Time to Contact You
Please let us know the best time to call and discuss your health quote.  * Morning  Afternoon  Evening  Anytime
Other Comments?

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All information provided on the information sheet is confidential and will be
used solely for the purpose of developing a quote for you.