First Name
Last Name
Address 1
Address 2
City
State
Zip
Daytime Phone
Evening Phone
Fax
Email
Best Time to Call
8-10 a.m.
10 a.m. - noon
Noon - 2 p.m.
2-4 p.m.
4-6 p.m.
6-8 p.m.
Birthday (mm\dd\yy)
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
19
Your Request
Please detail the specifics of your request here. Include what products or services you are interested in, if applicable
Additional Information
Enter the premium amount you have for deposit:
Are funds being trasferred from an (IRA, 401k, etc.)?
Yes
No
Are funds being transferred from another annuity?
Yes
No
When do you plan on buying an annuity?
--please select--
1-3 months
3-6 months
6-12 months
1-2 years
over 2 years
never
What is your relationship to the person buying this annuity?
--please select--
I'm buying an annuity for myself
I'm buying an annuity for a relative or friend
For an employee of our company
I am a licensed agent and financial planner
I'm an accountant
I'm an attorney
I'm an actuary
other
Are you comfortable purchasing ayour annuity through an internet insurance service like Direct Annuities?
Yes. I am comfortable purchasing my annuity through DirectAnnuities.com or a similar internet insurance service
No. I would only purchase my annuity from an insurance agent I could meet with in person.
Not Applicable. (For example, I am an Attorney or Accountant)