Term Insurance
Whole Life Ins.
Universal Life
Survivor Life
Mortgage Protection
Annuities
Pensions/401K
Key Man Coverage
Burial
Insurance
Long Term Care
Medicare Supplements
Save Up To 70% On Your Insurance!
"Your One Stop Financial Warehouse Where We Do All the Shopping!"
Annuity Quote Form
(Take less than 2 minutes to complete)
Free Online Annuity Quote Request
First Name:
Last Name:
Date of Birth:
(example: 06-04-64)
Gender:
Select
Male
Female
Address
City:
State:
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
Zip Code:
Day Phone:
Best time to call:
Choose Time
7 A.M. to 9 A.M.
9 A.M. to 11 A.M.
11 A.M. to 1 P.M.
1 P.M. to 3 P.M.
3 P.M. to 5 P.M.
5 P.M. to 7 P.M.
7 P.M. to 9 P.M.
9 P.M. to 11 P.M.
Evening Phone:
Best time to call:
Choose Time
7 A.M. to 9 A.M.
9 A.M. to 11 A.M.
11 A.M. to 1 P.M.
1 P.M. to 3 P.M.
3 P.M. to 5 P.M.
5 P.M. to 7 P.M.
7 P.M. to 9 P.M.
9 P.M. to 11 P.M.
Email Address:
Who is this quote for?
Me
Spouse
Parent
Child
Partner
Business Assoc.
Other
Tax Bracket:
15%
28%
31%
36%
39.6%
other
Amount of money you
want to invest:
(note $5,000 is a typical minimum)
$
If this is not a lump sum investment,
how much do you plan to add to
the annuity?
$
How often will you deposit
additional funds?
Monthly
Quarterly
Semi-annually
Annually
If any funds are coming from a
Tax Qualified account, what
type of account is it?
(leave blank if irrelevant)
None
IRA
SEP-IRA
Pension/Profit-Sharing
403b Annuity
Deferred Comp
If any funds are coming from a
Non-Tax Qualified account, what
type of account is it?
(leave blank if irrelevant)
None
CD
Savings Account
Mutual Fund
If funds are coming from
a CD, what month does it come due?
Not From CD
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Primary consideration influencing
annuity purchase:
Tax-deferral
Company offering annuity
Interest rate offered
Retirement planning
Safety of principal
Other consideration influencing
annuity purchase:
Tax-deferral
Company offering annuity
Interest rate offered
Retirement planning
Safety of principal
How long would you like your
annuity to grow before
receiving income payments?
1 Year
5 Years
10 Years
10+ Years
To Age 65
Would you like an additional quote?
Life Insurance
Disability Insurance
Long Term Care Insurance
Health Insurance
Group Health Insurance
Auto Insurance
Homeowners Insurance
Home Loans
Click Button Below When Done
Please Click Only Once . . . May take up to 30 seconds!
QwikInsurance.com (A Subsidiary of Premier Insurance Brokers)
Please Contact Us At Our Toll Free Phone Number: 1-847-241-6544
Privacy Notice/Copyright Info.
� 2016
Insurance-Web-Sales