What is your current
age? ___
Have you
set aside savings to cover any anticipated large expenses?
Yes No
Have you
set aside savings for financial emergencies? Yes No
If yes, how much
have you reserved? $___________
Excluding your home,
furnishings, and personal belongings, what would you estimate your net-worth to
be?
Less than
$100,000
$100,000 to
$500,000
$500,000 to
$1,000,000
More than
$1,000,000
What percentage of your net-worth is liquid? _____%
Have you included in your net-worth any annuities that are still
subject to surrender
charges? Yes No
If so, how much? $__________
How would you
describe your investment experience?
Very
sophisticated
Moderately experienced
Inexperienced
Is your current income sufficient to meet your needs?
Yes No
Other than customary adjustments for inflation, do you anticipate an
increase in your income requirements?
Yes No
If you were to purchase an annuity, when would you anticipate a need
to receive income from it?
During the
first year
Within 1 – 3 years After 3
years
I don’t
anticipate a need for income in the foreseeable future
If you were to purchase an annuity, when would you anticipate needing
access to 100% of the principal?
Within 1 – 4
years
Within 5 - 10 years
After 10
years
I don’t
anticipate a need for
my principal in the foreseeable future
If you purchase an annuity, what is your intended objective?
Income
Growth
Growth now
and income later
Pass values
to beneficiaries
Other (please describe):
If you purchase an annuity, what is the source of the premium?
Another
annuity
Life
insurance policy
Savings,
Checking, CDs
Reverse
mortgage or home equity loan
Other (please describe):
If you purchase an annuity, will your purchase involve a replacement
of any life insurance or annuity contract?
Yes No
If so, what type?
Traditional
Fixed
Index-Linked
Variable
If you purchase an annuity, will you incur a surrender charge?
Yes No
If so, what percentage
is the surrender charge? _____ %
