AFFIRMATIVE INSURANCE SERVICES 5624 Lankershim Blvd., North Hollywood, Los Angeles, California-91601. Phone: 818-997-7879 Fax: 818-997-7844 EMAIL: info@getais.com INSURANCE QUOTE: ANNUITY ANNUITY WORKSHEET Name: Address: City: State: Select... Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip Code: Phone: - - Ext.: Fax: - - Email: Who Referred You To Our Site? COVERAGE INFORMATION Date of Birth: / / Gender: Select... Female Male Annuity Type: Select... CD - Like SPDA, Rates Guaranteed, Specific Period FPDA - Flexible Premium Deferred Annuity SPDA - Single Premium Deferred Annuity SPIA - Single Premium Immediate Annuity Estimated Monthly Deposit: $. Estimated Lump Sum Deposit: $. Years of Growth Before Withdrawal: Where Are These Funds Coming From (Roll Over): Are These Funds Qualified (IRA,Pension): Select... Yes No Expected Payout: Select... Annuity Certain Cash Refund Option Lump Sum Distribution Joint & Survivor Option Life with Period Certain Installment Refund Option Life - Straight Life Option Questions or Comments to help the Agent: