Accumulation
Retirement Income
Principal Protection
Wealth Transfer
RIA Advisor Full Name (required):
RIA Email Address:
Product: select529AIG RIC-E TrustAllianz Index Advantage ADVAllianz Retirement Foundation ADVAmeritas Advisor No-Load VAAmeritas Advisor VULAmeritas Compass SPIAAmeritas Term InsuranceAOR ProductCOVR DisabilityCOVR LifeCOVR LTCEFLS Legacy VAGreat American Index Protector 7Great American Protector 4Great American Protector 5 MVAGreat-West Smart Track AdvisorJackson Elite Access Advisory II VAJackson Market Protector Advisory FIAJackson Perspective Advisory II VAMutual FundNationwide New Heights 9Pacific OdysseySymetra Advisory Edge 5Symetra Advisory Edge 7Symetra Advisory Income Edge 7TIAA Intelligent Variable AnnuityTIAA Investment HorizonsTransamerica Advisor's EdgeTransamerica Advisor EliteTransamerica I-Share
Death Benefit: selectEdgeFoundationMaxOtherPlusRICRIMArchitectISFLnone
Living/Withdrawal Benefit: selectAnnual Step-upDouble EnhancedPolicy ValueReturn of PremiumStep UpUnknownAdditional Death Benefitnone
Other Rider:
Is this a trust? selectYesNo
Name of Trust
Owner First Name
Owner Last Name
Owner DOB
Owner SSN
Owner Gender MaleFemaleEntityOtherUnknownUnisex
Owner Phone
Owner Email
Owner Street
Owner City
Owner State
Owner Zip
Joint Owner First Name
Joint Owner Last Name
Joint Owner DOB
Joint Owner SSN
Joint Owner Gender MaleFemaleEntityOtherUnknownUnisex
Joint Owner Phone
Joint Owner Email
Joint Owner Street
Joint Owner City
Joint Owner State
Joint Owner Zip
Annuitant First Name
Annuitant Last Name
Annuitant DOB
Annuitant SSN
Annuitant Gender MaleFemaleEntityOtherUnknownUnisex
Annuitant Phone
Annuitant Email
Annuitant Street
Annuitant City
Annuitant State
Annuitant Zip
Joint Annuitant First Name
Joint Annuitant Last Name
Joint Annuitant DOB
Joint Annuitant SSN
Joint Annuitant Gender selectMaleFemaleEntityOtherUnknownUnisex
Joint Annuitant Phone
Joint Annuitant Email
Joint Annuitant Street
Joint Annuitant City
Joint Annuitant State
Joint Annuitant Zip
Beneficiary First Name
Beneficiary Last Name
Beneficiary Relation to Owner
Beneficiary DOB
Beneficiary Percent
Second Beneficiary First Name
Second Beneficiary Last Name
Second Beneficiary Relation to Owner
Second Beneficiary DOB
Second Beneficiary Percent
Third Beneficiary First Name
Third Beneficiary Last Name
Third Beneficiary Relation to Owner
Third Beneficiary DOB
Third Beneficiary Percent
Fourth Beneficiary First Name
Fourth Beneficiary Last Name
Fourth Beneficiary Relation to Owner
Fourth Beneficiary DOB
Fourth Beneficiary Percent
Electronic Delivery selectYesNo
Advisor Fees From Account selectYesNo
Frequency of Auto Rebalancing
Start of Rebalancing
Telephonic/Electronic Trading selectYesNo
Tax Withholding selectYesNo
Fund (or index for FIA)
Percent (must equal 100)
Fund One Name
Fund One Percentage
Fund Two Name
Fund Two Percentage
Fund Three Name
Fund Three Percentage
Fund Four Name
Fund Four Percentage
Fund Five Name
Fund Five Percentage
Fund Six Name
Fund Six Percentage
Fund Seven Name
Fund Seven Percentage
Fund Eight Name
Fund Eight Percentage
Fund Nine Name
Fund Nine Percentage
Fund Ten Name
Fund Ten Percentage
