Reliable Financial Group

To print just this form highlight entire form, click file and print, click selection, and print.
Once completed, please fax the form
to FRANK SKAW at 509-921-1755.
Fields marked with a * are required.

* Broker Name
* Address
* City
* State
* Zip
Phone
Fax
E-mail Address
CLIENT:
Annuitant
* Name
* Birth date
* Gender	Male Female
Joint Annuitant
Name
Birth date
Gender	Male Female
ANNUITY:
Insurance Company Preference if any
State of Issue
Tax Qualified	Yes No
Select one of the following
Annuity products:

Single Premium Deferred	Single Premium Deposit $
Flexible Premium Deferred	Annual Dep $ or Monthly Dep $
Single Premium Immediate	Single Premium Deposit $ or
	Modal Benefit Desired $
Benefit Mode	Annual Semi-Annual Quarterly Monthly
Date of Deposit
Date of Initial Benefit:
	Life Only Life and Years Certain
	Year certain only # of years: Installment Refund
Quote Impaired Risk SPIA?	Yes No
Describe Medical Conditions
Additional Information:
Please list any additional comments or competition information that will assist us in properly preparing your quote.

Your request cannot be honored unless this form is completed.

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Web site Created: September 2002

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