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1.800.456.7999 We specialize in people over products

Annuity Illustration

At Insurance Network America, we have access to numerous carriers with a diverse offering of fixed, fixed index, and immediate income annuities, and a strong desire to write your business this year. Upon completion of this form, our annuity specialists will immediately search those portfolios of products to find the ones that best meet the objectives of your clients, their need for access, their long term goals for the money, and their interest rate guarantee criteria.


Agent Name:*  

Agent Phone Number:*

Client Name:

Client Gender:


Client Date of Birth:

State of Issue:

Initial Premium:

Source of Funds:

Tax Qualified?



Primary Purpose of Annuity

Target Payout Amount (If Immediate Annuity):   

Payout Term:

 5 year period certain
 10 year period certain
 20 year period certain
  Life only
  Life and 10 year certain
 Life and 20 year certain

Payout Frequency:



Other Term or Frequency and Additional Information