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International Corporate Benefits, Inc.
PO Box 420003 Atlanta, Ga. 30342
Tel: 404-845-0500 Fax: 404- 845- 0505

Annuity Quote Request
Fill in the form below to receive an Annuity Product Quote
Fields that are BOLD must be filled

Client Information

Annuitant
First Name:
Last Name:
Date of Birth: [mm/dd/yyyy] format
OR
Age: [Actual or Nearest]
Gender:	Male Female
Email:
Phone Number:

Joint Annuitant Information
Click on the Checkbox to enter Joint Annuitant information

Annuity

Insurance Company Preference if any:
State of Issue:
Tax Qualified:	Yes No

Select One of the following annuity products:
YOU MUST SELECT ONE OF THE FOLLOWING PRODUCTS

Benefits

Benefit Mode:	Annual Semi-Annual Quarterly Monthly
Date of Deposit:
Date of Initial Benefit:
Life Only	Life and Years Certain
Year Certain Only/#of Years	Installment Refund

Additional Information

Quote Impaired Risk SPIA?

Yes No

Describe Medical Conditions

Additional Information
Please list any additional comments or competition information

Agent Information
FOR AGENT USE ONLY

Your request cannot be honoured unless this form is completed.

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