CPS-Reliable Financial Group
Experts in Business, Estate and Personal Life Planning
A CPS Insurance Services, Inc. Affiliated Office
 
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Annuity Quote Request
Fill in the form below to receive an Annuity Product Quote:

* Denotes Required Field
* Broker Name:
*Address:
*City:
*State:
*Zip:
Phone #:
Fax #:
E-mail Address:
Return Method: Fax   Mail   Broker Pick-Up E-mail
Client:
Annuitant  
*Name:
*Birth date:
*Gender: Male   Female
Joint Annuitant  
Name:
Birthdate:
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 Deposit $ or Monthly Deposit $
Single Premium Immediate
Single Premium Deposit $ or
Modal Benefit Desired $
Benefit Mode: Annual   Semi-Annual   Quarterly   Monthly

Date of Deposit:
Date of Initial Benefit: 00/00/0000
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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