WGG - Disability Introduction

Variable Annuity Quote:

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VARIABLE ANNUITY QUOTE REQUEST
Please complete the following information if you would like to obtain a Variable Annuity quote. Please understand this form is not an application. We will first contact you with a quote, then an application and prospectus will be sent to you if coverage is desired. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?	Last
	First
	Middle
What is your e-mail address?	e-mail
What state do you reside in?	State
What is your tax bracket?	Tax Rate
What is your telephone number?	Telephone
What is your fax number?	Fax
What is your birth date?	Birth Date
What is your gender?	Gender	Male Female
When do you plan to retire?	Anticipated Retirement Age (example 65)
Interest in this Annuity?	Who is it for?	Yourself Relative Friend Employee
Is the money being deposited Qualified Funds?	(Are you bringing them over from an IRA, SEP, Keogh, Pension, or 401(k)?	Yes No
Terms
What terms would you prefer for your quote?	A monthly income that pays out for the lifetime of the annuitant, no matter how long the annuitant lives.	This will generate the maximum monthly payout.
	A monthly income that pays out for the lifetime of the annuitant, and at least 10 years certain no matter how long the annuitant lives.	This will generate less than the maximum monthly payout.
	A monthly income that pays out for the lifetime of the annuitant, and at least 20 years certain no matter how long the annuitant lives.	This will generate even less then the plan above.
To request a quote, make one selection, fill in the amount for that selection, then click on the submit button. For additional quotes, repeat the procedure.
Annuity Quote based on an amount deposited
Variable Annuity	Monthly payments starting at the anticipated retirement age	Make a Lump Sum Deposit (one) or Monthly Deposits (continuing until retirement age) Amount of one Deposit:
Quote based on monthly income needed
Desired Monthly Income	Amount
Variable Annuity	Lump Sum Deposit required for desired monthly income to start at the anticipated retirement age.	Monthly Deposit required for desired monthly income to start at the anticipated retirement age.
Best Time to Contact You
Please let us know the best time to call and discuss your quote.	Morning Afternoon Evening Anytime	Or specify other:


	Wealth Guardian Group 3969 E Brae Voe Way \| Queen Creek, AZ 85240 Phone (480) 987-9951 Fax (480) 445-9319

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