Applicant Information: ID# 656254

Name: XXXX XXXXXXXX
Gender: XXXXXXXX
Birth date: 12/14/48
Address: XXXXX XXXXXXXXXX XXXX
City: Jacksonville
State: Florida
Zip: XXXXX
Work Phone: XXX-XXX-XXXX
Home Phone: XXX-XXX-XXXX
Best Time To Call: 8-10 a.m.
E-mail Address: xxxxxx@earthlink.net

Your Personal Tax Information:

Your tax bracket: 39%
Funds from a Tax Qualified Account? Yes
If “Yes” what type of account? 401K
Funds from a Non Tax Qualified Account? No
If “Yes” what type of account? N/A
If a “CD”, the month the CD comes due? N/A

Quote Information:
Are you requesting for yourself? Yes
If “No”, who is request for? Me

Investment (Funds) Information:

Amount of money that you wish to invest: 750,000.00
Is this a lump sum? Yes
If “No” how much do you plan to add later? N/A
How often do you plan to deposit additional funds? Annually

Your concerns:
Primary reason for annuity purchase: Retirement
Other reasons for annuity purchase: Interest Rate
How long would you like your Annuity to grow? 10+ years