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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? Annual Semi-Annual Quarterly Monthly These income payments would need to begin when? 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?