CALL TOLL-FREE 1.888.505.7526 (PLAN) Immediate Quote Colorado Insurance Group, LLC Immediate 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: Applicants Date of Birth: Applicants Sex: Male Female JOINT APPLICANT INFORMATION Joint Applicants Name Joint Applicants Date of Birth: Joint Applicants Sex: Male Female SECTION III: QUOTE INFORMATION State Amount of premium available: Premium Type Qualified Non-Qualified How often will the income need to be paid? Annually Semi-Annually Quarterly Monthly When would these income payments need to begin? Choose the payout method X years certain Life only - no refund or uncertain period Life with X years certain Life with installment refund Joint and survivor 100% Joint and survivor 75% reduced at either death Joint and survivor 67% reduced at either death Joint and survivor 50% reduced at either death Joint and survivor 75% reduced at primary's death Joint and survivor 50% reduced at primary's death Joint and survivor 100% with X years certain Joint and survivor 100% with cash refund Years certain(X from above): 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.