Annuity Information Sheet

Together, We Protect What Matters Most

A case manager will contact you if any additional information is needed for suitability approval or for the transfer of funds, such as account statements or other required documents.

Important Notice: Your privacy is our priority. Your personal and health information is collected and stored through a compliant secure system. We do not sell your data, and it is only shared with authorized insurance carriers as required for underwriting and policy issuance. Submitting this application does not guarantee approval.

Form Type *

Annuity
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Agent Name

Agent Email

Applicant's Information

First Name *

Last Name *

Gender *

Male
Female
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Email *

Phone *

Date of birth (m/d/yyyy) *

Social Security Number *

US Residency Visa Status *

U.S. Citizen
U.S. Permanent Resident (Green Card holder)
Non-Resident Alien
Visa or Work Permit Holder
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Please upload a clear picture of the Visa or Work Permit

IPA Owner Visa Work Permit File Upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF “Don’t have this right now? No worries — you’ll receive a link by email to upload it later.”

Country of Birth *

State of Birth *

Address *

Street Address

City

State

Country

Postal Code

Years at Address *

Marital Status *

Single
Married
Divorced
Widowed
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Primary Source of Income

Employment Status *

Employed (full-time or part-time)
Self-Employed
Unemployed
Retired
Homemaker
Student
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Employer Name *

Employer Address *

Type of Business *

How long have you been employed? *

Position *

Annual Income *

$

Type of Business

How long have you been self-employed? *

How long have you been unemployed? *

How long have you been retired? *

Beneficiary Information

Primary Beneficiary Full Name *

Primary Beneficiary Relationship to Policy Owner *

Primary Beneficiary Date of Birth (m/d/yyyy) *

Primary Beneficiary SSN *

Primary Beneficiary Percentage *

Secondary Beneficiary Full Name *

Secondary Beneficiary Relationship to Policy Owner *

Secondary Beneficiary Date of Birth (m/d/yyyy) *

Secondary Beneficiary SSN

Secondary Beneficiary Percentage *

Contingent Beneficiary

Contingent Beneficiary #1 (If Primary Beneficiary passed away before the Contingent Beneficiary) *

Add

Don't Add

Contingent Beneficiary 1 Full Name *

Contingent Beneficiary 1 Relationship to Policy Owner *

Contingent Beneficiary #1 Date of Birth (m/d/yyyy) *

Contingent Beneficiary #1 SSN

Contingent Beneficiary #1 Percentage *

Contingent Beneficiary #2 (If Primary Beneficiary passed away before the Contingent Beneficiary) *

Add

Don't Add

Contingent Beneficiary #2 Full Name *

Contingent Beneficiary 2 Relationship to Policy Owner *

Contingent Beneficiary #2 Date of Birth (m/d/yyyy) *

IPA Contingent Beneficiary #2 SSN

Contingent Beneficiary #2 Percentage *

Funding & Account Transfer Information

Will this annuity replace or change any existing annuity or life insurance policy? *

Yes

No

Company Name - company that currently holds your account *

Company Mailing Address *

Company city and state *

Company Phone Number

Contract Number *

How much will you be starting this account with? *

$

How will this account be funded? *

Current savings/checking account
Sale of investments or property
Inheritance
Rollover/transfer from IRA, 401(k), or pension
Other
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Please Specify *

Purpose of this Account *

Retirement Income

Long-Term Savings

Growth/Wealth Accumulation

Legacy/Estate Planning

Protecting my money from market loss

Other

Please specify (if other)

Upload your most recent account statement (Annual statement or latest available statement is acceptable)

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF “Don’t have this right now? No worries — you’ll receive a link by email to upload it later.”

How long do you plan to keep this money in the account? *

Less than 3 years

3 – 5 years

6 – 10 years

More than 10 years

Risk Tolerance *

Conservative — I want stability and preservation of principal

Moderate — I can handle some fluctuation for better growth

Aggressive — I am comfortable with higher risk for higher potential returns

Do you have at least 6 months of living expenses saved in other easily accessible accounts - not including this account *

Yes
No
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Household Annual Income (Husband and Wife income convined) *

Less than $25,000
$25,000 – $49,999
$50,000 – $99,999
$100,000 – $249,999
$250,000 - $500,000
$500,000 - $1,000,000
$1,000,000 - $5,000,000
$5,000,000 - $10,000,000
$10,000,000 +
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Household Net Worth (Husband and Wife networth convined) *

$100,000 – $249,999
$250,000 – $499,999
$500,000 – $999,999
$1,000,000 - $5,000,000
$5,000,000 - $10,000,000
$10,000,000 +
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Household Liquid Net Worth (easily accessible assets such as cash, stocks, savings) *

Less than $25,000
$25,000 – $49,999
$50,000 – $99,999
$100,000 – $249,999
$250,000 - $500,000
$1,000,000 - $5,000,000
$5,000,000,+
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Federal Income Tax Bracket (Your approximate federal tax rate) *

0–12%
13–22%
23–32%
33–37%
Not Sure
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Liquidity and Access Needs

Do you anticipate needing access to these funds within the next 3–5 years? *

Yes

No

How Much? *

$

When? *

Do you have at least 6 - 12 months of living expenses in liquid assets outside of this account? *

Yes

No

Other Information

Driver License Number *

Driver License Expiry Date (m/d/yyyy) *

Please Upload a clear copy of your Driver License, Passport or A Government Identification

Owner Driver License Passport ID File Upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF “Don’t have this right now? No worries — you’ll receive a link by email to upload it later.”

Client's Consent *

By signing below, I acknowledge that I have reviewed all information contained in this application. I confirm that the information provided is true, complete, and accurate to the best of my knowledge.

I am aware that providing false information may result in claim denial or policy cancellation.

Signature *