CALL TOLL-FREE 1.888.505.7526 (PLAN) Flexible Premium Quote Colorado Insurance Group, LLC Deferred Annuity Questionnaire SECTION I: AGENT INFORMATION Full Name of Agent * Address Line 1 Address Line 2 City, State, Zip E-Mail * Business Phone * Cell Phone Home Number Fax Number SECTION II: APPLICANT INFORMATION Applicants Name: Date of Birth: Sex: Male Female SECTION III: QUOTE INFORMATION Requested Carrier/Product (if any) State Amount of premium available The source this premium comes from: (cash, IRA, 1035, CD) Premium Type Qualified Non-Qualified Any surrender period requirements? Cost Basis Will monthly income be needed? Yes No If yes, please specify: How often would the income need to be paid? Annually Semi-Annually Quarterly Monthly When would these income payments need to begin? When will funds be available for this case? SECTION IV: CASE INFORMATION Are you in competition for this case? Yes No I don't know If yes, please specify: Any additional comments? Copyright © 2010 Colorado Insurance Group, LLC. All Rights Reserved.