Annuity Quote Request Form

Hansen Brokerage Services

Toll: 800-746-3544
Tel: 616-940-4004
Fax: 616-940-4033
quotes@hansenbrokerage.com

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Fill in the form below to receive a Product Quote:

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Annuity Quote Request Form

Broker Name *

Address *

City *

State *

Zip *

Email Address *

Phone Number

Fax Number

Return Method Fax Mail Broker Pick-Up E-mail

Client Information

Annuitant

Name *

Birthdate *

Sex Male Female *

Joint Annuitant

Name

Birthdate

Sex Male Female

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

or Modal Benefit Desired $

Benefit Mode Annual
Semi-Annual
Quarterly
Monthly

Date of Deposit

Date of Initial Benefit

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

Number of years, if applicable

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.

Additional Information:

Your request cannot be honored unless this form is completed.

Security Captcha

Quote Request Submitted!

Thank you and have a great day!

Hansen Brokerage Services, Inc., 5380 Cascade Road SE, Suite 150, Grand Rapids, MI 49546
Phone: 800-746-3544 Fax: 616-940-4033 Email: scott@hansenbrokerage.com
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