Brass Ring Financial Solutions – Annuity Center
Fixed, MYGA, Fixed Index, SPIA

Broker Name_________________________________ Affiliation: __________________________

Telephone # ( )___________ Fax # ( )______________Email Address______________________


City, State, Zip________________________________________________________________________

Illustration to be received by: Mail____ Fax____ Email____

Client Name: __________________________________________ D.O.B. ________________________

Sex: □ M □ F

State: _______ Net Annual Income: ________________ Occupation_____________________________

Deposit Amount: ___________________ Qualified Money: Y__ N__ Non-Qualified Money: Y__ N__

Single Premium: Y__ N__ 1035 Transfer: Y__ N__

Type of Annuity:

Fixed: Y ___ N____

MYGA: Multi-Year Guarantee Rate: Length of Term _____# of Years. Bonus: Y__ N__

Fixed Index Annuity: ______ Bonus: Y__ N__

SPIA: Type: (please circle) Life, Life with Term Certain, Period Certain: Indicate # of years ___

COMMENTS: ________________________________________________________________________


Please submit the Life Quote information via email:
John C. Massolio III, CLU ChFC 888-651-0025

We will provide you the best quotes from the industry’s leading carriers.