Quote Questionnaire

AIG/Anchor National

AIG/Sun America

Allstate

American Skandia

AXA-Equitable Life

First Colony

Genworth
      (GE Life & Annuity)

Hartford/Planco

ING/Aetna

ING/Golden American

ING/Reliastar

ING/USG Annuity

Integrity Life

Jackson National Life

Jefferson Pilot

John Hancock Funds

John Hancock
      (formerly Manulife)

Lincoln Benefit

Lincoln Life

Mass Mutual

MetLife Investors

MetLife/New England

Nationwide/BOA

Nationwide Life

New York Life

Ohio National

Pacific Life

Penn Mutual Life

Phoenix Life

Prudential

Putnam-Allstate

Putnam-Hartford Annuities

Scudder

Sun Life Financial

Sun Life of Canada

Sun Life-Keyport

Symetra
      (formerly Safeco)

Transamerica Capital

Travelers Life & Annuity

Fields marked with (*) are required.

Please select one*:
Send via email     Phone prior to sending

First Name*  

Last Name   

Phone Number*   ( ) -
(In case we need to clarify any information)

Email Address*   

Participant Information

Name of the purchaser (owner) of the annuity*   

Owner's date of birth*   --Select-- January February March April May June July August September October November December --Select-- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 --Select-- 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Owner's state of residence*    --Select-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Owner's sex*   --Select-- Male Female

(Click here if owner and annuitant are the same person)

Name of person who will be the annuitant.*   
(Usually the same as the owner.)

Annuitant's date of birth*    --Select-- January February March April May June July August September October November December --Select-- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 --Select-- 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
(if different from the owner)

Annuitant's state of residence*    --Select-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
(if different from the owner)

Annuitant's sex*    --Select-- Male Female
(if different from the owner)

Name of the person(s) who will be the primary beneficiary.   
(This is who will receive the annuity in the event of the annuitant's death.)

Annuity Information

Dollar amount of your deposit for which you want a quote.*   

Are the funds Qualified or Non-Qualified?*    --Select-- Qualified Non-Qualified Unsure
(Qualifed is from an IRA, pension plan, etc.)

Is this a Rollover?*    --Select-- Yes No Unsure
(Rollover is from another annuity/1035 exchange)

Which type of annuity would you prefer:*    --Select-- Fixed Annuity (Traditional) Fixed Annuity (Indexed) Variable Annuity Unsure
[click for description: fixed vs. variable]

Select those benefits that are important to you: *
(Not all benefits are available in all states or with all annuities)

   Lifetime Income Benefit (LIB) (click for more info)

   Guaranteed Minimum Income Benefit (GMIB) (click for more info)

   Guaranteed Minimum Accumulation Benefit (GMAB) (click for more info)

   Guaranteed Minumum Withdrawal Benefit (GMWB) (click for more info)

   Guaranteed Lifetime Withdrawal Benefit (GLWB) (click for more info)

   Shortest possible surrender fee period

   Account Value Step Up Benefit

   Dollar Cost Averaging Benefit

   Automatic Asset Rebalancing Benefit

   None

   Other (please specify):

Timeline for annuity purchase*    --Select-- Within 30 days 30-60 days Less than 6 months More than 6 months

When would you like to begin receiving regular income payments from the annuity?*    --Select-- Immediately (Not available with Indexed Annuities) Within a year 1-5 years 5-10 years Longer than 10 years

Purpose of this annuity (and comments or questions)*   

Before investing, investors should carefully consider the investment objectives, risks, charges and expenses of the variable product and its underlying investment options. The current contract prospectus and underlying fund prospectuses, which are contained in the same document, provide this and other important information. Please contact your representative or the Company to obtain the prospectuses. Please read the prospectuses carefully before investing or sending money.