PENTECO Insurance-Life Insurance, Disability Insurance, Health Insurance

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*Name:

*Address:

*City:

*State:

ZIP:

*Birth date:

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Do You Need Income from Your Investments Now? Yes No
(If "YES," an Immediate Annuity probably is the type of annuity you are looking for)

Are your Investment Funds "Tax-Qualified," like an IRA or a 401(k)?Yes No

Do you want the quote based on
A Single Life Income? Yes No
If Joint Lifetime Income desired, please indicate Spouse DOB in the Comments field, below)

Investment Funds Available:

Household Annual Income:

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