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ILLUSTRATION REQUEST

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This field is for validation purposes and should be left unchanged.

Are you filling out an annuity or life illustration?*

Annuity

Life Illustration

Agent's Name (First & Last Name):*

Agent's Email:*

Client's Name (First & Last Name):*

Client's Gender:*

Male

Female

Add Spouse

Spouse's Name (If Joint):*

Spouse's Gender:*

Male

Female

Client's Age:*

Spouse's Age:*

State:*

Product Preference:

Premium:*

Type of Funds (Q or NQ)*

Flexible Premium?

Yes

$/Annually*

From Age:

Through Age:

What is the primary goal and objective?*

Growth

Max Income

Legacy

Single or Joint Payments?*

Single

Joint

Income Deferral Period (Age):*

Spouse's Name (If Joint):*

Spouse's Age:

Notes:

Advisor's Name (First & Last Name):*

Advisor's Email:*

Meeting Scheduled for:

MM slash DD slash YYYY

Client's Name (First & Last Name):

State:

Male

Female

Joint

Date of Birth / Age(s):

Goal of Insurance:

Year Income Desired:

Premium:

Premium Duration:

Face Amount:

Specified Amount:

LTC:

Yes

Smoking / Tobacco Use:

Tobacco

Non-Tobacco

Rating Classification:

Sub Standard Health Concerns (Please Be Specific Below)

Health Concerns / Additional Notes:

IF YOU HAVE ANY QUESTIONS ABOUT THIS FORM PLEASE CONTACT KYLE AND HIS TEAM:

800.440.1088

SCHEDULE A CALL

CONTACT US

Toll Free: 800.440.1088
Voice: 480.949.1088
Fax: 480.949.2427

18700 N. Hayden Rd., Suite 310
Scottsdale, AZ 85255

The Quantum Group® provides marketing, distribution, training, and support services for annuity and insurance products offered through licensed insurance carriers to financial professionals.

The Quantum Group, USA, LLC, an Arizona limited liability company. In CA, d/b/a Quantum Distribution & Insurance Services LLC. License # 0M85682. The Quantum Group, USA, LLC. is licensed in all states except Alaska and New York.

CONNECT WITH QUANTUM

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Home
Our Story
- Ron Shurts
Meet the Team
Our Services
Blog
- FAQs
Careers
Contact
Advisor Login
Socials
- Calendar
- Facebook
- LinkedIn
- Instagram
- x / twitter
- Soundcloud
- Youtube
- Phone