Annuity Quote

Fill in the form below to receive a Annuity Product Quote from PIPAC LIFE Brokerage.

Broker Information:

Broker Name:
City: State:   Zip:
Phone:   Fax:
E-Mail Address:
Return Method: Fax Mail Broker Pick-Up E-Mail

Client Information:

Annuitant Information

Date of Birth
Sex Male Female

Joint Annuitant Information

Date of Birth
Sex Male Female

Annuity Information:

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:

Life Only
Life and Years Certain
Year certain only/ # of years:        Installment Refund

Quote Impaired Risk SPIA?

Yes No

Describe any Medical Conditions

Additional Information:

Please list any additional comments or competition information that will assist us in properly preparing your quote.