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SUBMISSION FORM

Client Name*
First Last
Carrier
Policy #
Writing Advisor
Split Code
Untitled
- Life
- Annuity
Untitled
- Lump Sum
- Multiple Payments
Frequency
- Annual
- Quarterly
- Monthly
Phone
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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.

For producer use only.