Ask a Specialist : Western

Agent Name:

Agent Phone Number:

Agent Email:

Client Name:

Age:

Gender:

State:

Proposed Annuity Amount (Min: $5,000):

Spouse Name:

Spouse Age:

Where is the money coming from:

Do you want RMD's shown on the illustration?

YESNO

Is this account coming from an active employment sponsored plan?YESNO

Please have your client consult his/her HR department to see if this money is eligible for rollover. Typically you cannot move active retirement accounts.

Please select the following statement that best describes your clients primary goal:

Is the client currently taking withdraws/income from this account? If so, how much?

If not taking withdraws/income at what age does the client anticipate taking withdraws/income? *If not planning on taking write "n/a"

Additional Comments:

Attachment 1:

Attachment 2:

Attachment 3:

Release of Information Acknowledgement/Agreement

My client has authorized me to share their private information, including but not limited to, their Date of Birth, personal account information and account statement to the Integrity Marketing Group, LLC and Insurance carriers only as deemed necessary. This information will solely be used for the purpose of advising on a product for the client and will NOT be sold to or shared with any 3rd parties for the use of leads or other marketing purposes.