Owner Information

First Name

Middle Name

Last Name

Date of Birth

Age

Gender

Entity

Tax Status

Relationship to Annuitant(s)

Form of Ownership

Supporting documents (list)

Financial Information

Annual Income

Source of Income

Annual Household Income

Existing Assets

Existing Liquid Net Worth

Do you currently own any annuities?

Yes

Please List Current Annuities

Do you currently own life insurance?

Yes

Please List Current Life Insurance

Questionnaire

	Yes	No
Does your income cover all your living expenses including medical?
Do you expect changes to your living expenses?
Do you anticipate changes in your out-of-pocket medical expenses?
Is your income sufficient to cover future changes in your living and/or out-of-pocket medical expenses during the surrender charge period?
Do you have an emergency fund for unexpected expenses?

Why are you purchasing this annuity?

Describe your investment experience by type and length of time.

What is the source of the funds for the purchase of the proposed annuity?

How many years from today will you need access to your funds without a penalty?

Will the proposed annuity replace any product?

Yes

Will you pay a penalty or other charge to obtain these funds?

Yes

What is the amount of the charge or penalty you are willing to pay?

Additional Information

Acknowledgements and Signatures

I understand that should I decline to provide the requested information or should I provide inaccurate information, I am limiting the protection afforded me by the Florida Statutes regarding the suitability of this purchase.

Acknowledgements

I REFUSE to provide this information at this time.

I have chosen to provide LIMITED information at this time.

My annuity purchase IS NOT BASED on the recommendation of this agent or the insurer.

My annuity purchase IS BASED on the recommendation of this agent or the insurer.

Owner’s Signature

Sign Here

Date Signed

Financial Suitability Questionnaire

Owner Information

Financial Information

Acknowledgements and Signatures

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