Deferred Annuity Questionnaire

SECTION I: AGENT INFORMATION
* Full Name of Agent
Address Line 1
Address Line 2
City, State, Zip
* E-Mail
* Business Phone
Cell Phone
Home Number
Fax Number

SECTION II: APPLICANT INFORMATION
Applicants Name:
Date of Birth:
Sex:
Male
Female

SECTION III: QUOTE INFORMATION
Requested Carrier/Product (if any)
State
Amount of premium available
The source this premium comes from: (cash, IRA, 1035, CD)
Premium Type
Qualified
Non-Qualified
Any surrender period requirements?
Cost Basis
Will monthly income be needed?
Yes
No
If yes, please specify:
How often would the income need to be paid?
Annual
Semi-Annual
Quarterly
Monthly
These income payments would need to begin when?
When will funds be available for this case?

SECTION IV: CASE INFORMATION
Are you in competition for this case?
Yes
No
I don't know
If yes, please specify:
Any additional comments?

Securities Offered Through Variable Life Brokerage Distributors
a division of ING Financial Partners, Inc.
Member SIPC
Diversified Underwriters Services Inc., is not a subsidiary of nor controlled by VLBD/ING Financial Partner, Inc.

© 2005 Diversified Underwriters Services, Inc. Portions ©2005 BISG, Inc.