Fixed Annuity Selector

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Fixed Annuity Selector

As you begin the process of planning your clients’ retirement income, this annuity selector form will help you gather pertinent information about their goals. This questionnaire is a starting point, meant to help you determine the appropriate fixed annuity options for your clients, and then generate illustrations and product information accordingly.

If you have questions, please email insurance@dbs-lifemark.com or call:

Jim Boldischar: 877.593.7655

All completed forms are submitted via our secure server so you can be assured that your information is safe with us.

Name of Advisor you are working with:
First Last
Applicant/Owner's Name*
First Last
Applicant's phone number*
Applicant's email*
Is annuitant other than Applicant/Owner?*
- Yes
- No
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender:*
- Male
- Female
State of Residence*
State
Date of Birth*
MM slash DD slash YYYY
Gender:*
- Male
- Female
Premium Type*
- Qualified
- Non-Qualified
Spouse’s Name
First Last
Spouse's Date of Birth
MM slash DD slash YYYY
Spouse's Gender:
- Male
- Female
Premium Amount*
1035X, if so replace:
- Life
- Annuity
Type of Annuity
- Fixed Rate
- Index Based
- SPIA
Primary Objective*
- Accumulation
- Income
- Wealth Transfer
- LTC
What (if any) is the need for annual access to a percentage of the account value?
- Yes
- No
Percentage:*
Is income the primary goal?*
- Yes
- No
How many years will distributions begin?*
What is most important?*
- Guarantees
- Potential Performance Assumptions
Income Preference (select all that apply):*
If select period is chosen, how many years?

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Phone 800.869.1DBS / 952.697.5000
Fax 952.697.5001

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Securities offered through The Leaders Group, Inc. Member FINRA/SIPC. 26 W. Dry Creek Circle, Suite 800, Littleton, CO 80120, 303.797.9080. Diversified Brokerage Services is not affiliated with The Leaders Group, Inc.

Before investing, research the background and registration status of any firm or financial professional you are considering dealing with at: http://brokercheck.finra.org/