Annuity quote Form

Complete this form to receive a personalized annuity quote.

Name:
Age:
Birthdate:	, 19
Sex:	Male Female
Home phone #:	()-
Work phone #:	()- Ext
Best place and time to call:
Email address:
City:
State:

Where would the money for your annuity come from (i.e., CD, IRA, Roth IRA, 401k, other annuity, etc. In other words, is it before tax money, or after tax money)?:

When would you like to start the annuity? Year:

Type of annuity:

Single Premium Immediate (Income) Annuity -- you invest a lump sum and start receiving income right away.
Single Premium Deferred (Growth) Annuity -- you invest a lump sum and let the money grow for later use. Meanwhile you can access some of the money if needed.
Flexible Premium Deferred (Growth) Annuity -- you make multiple contributions over time and let the money grow for later use. Meanwhile you can access some of the money if needed.

Please Advise.

Please answer the following only if you chose the Single Premium Immediate Annuity; otherwise skip to the next section.

Do you have a specific lump sum amount in mind that you want to invest, or do you have a goal of a certain amount of income you want and therefore you need to see how much of a lump sum it would take?
Lump sum of $
or desired income of for

Extra Credit:
Health Status (poor health may get you higher income):

Please answer the following only if you chose a Deferred Annuity; otherwise skip to the last part.

Amount you will invest as a contribution: $

Objectives: Please number (from 1 to 3) in order of importance.
Safety of Principal: Growth: Liquidity:

Comments or questions:

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The PGA Financial Co. PGAFinancial.com
Call: (714) 897-0955, Toll Free: (877) 336-5490, Fax: (714) 891-1331
E-mail: Service@PGAFinancial.com
13736 Goldenwest Street,
Suite H
Westminster, CA 92683
Lee Martinson

Licensed in Arizona, California (license #0629626), Oregon, Texas, and Virginia. For other states, inquiries are referred to agents licensed to handle insurance in that particular state.

PGA Financial has no intent to generate interest in any particular life insurance company or specific annuity, but rather to inform and educate you on the general concept -- after which, if you are interested, a broker/agent at PGA Financial will be glad to research companies that offer such plans, get you a quote and assist you in making a choice. If you do become interested and obtain a policy, the broker would be compensated by the insurance company.