AdvisorNet Insurance

Agent Name	Agent Email
Deliver Illustration via Email Fax	Date Illustration Needed
Do you need to be contracted? Yes No	Send Application / Brochure kit? Yes No

Name	Date of Birth
Gender Male Female	State of Residence

SPIA (Single Premium Immediate) SPDA (Single Premium Deferred) Surrender Period Length? FPDA (Flexible Premium Deferred) Indexed Annuity Surrender Period Length? Income Rider Yes No

Input Premium Amount $ Input Income Amount $
Input Cost Basis Amount $
Frequency of Payout Monthly Quarterly Semi-annually Annually
Qualified Non-Qualified

Not Life, just a period of certain years / How many years?
Individual Life only Life with period of certain years How many years? Life with Installment Refund Life with Cash Refund
Joint
Joint Annuitant Name	Date of Birth
Gender Male Female	State of Residence
Amount 50% 100% Life only Life with period of certain years How many years? Joint Life with Installment Refund Joint Life with Cash Refund