Dallas Financial Wholesalers

Fill in the form below to receive a New Generation IRA Quote.
NOTE: All fields are required to produce your quote.

BROKER
Broker Name:
City:
State:
Zip:
Phone Number:
Fax Number:
E-mail Address:
Return Method:	E-mail Fax Broker Pick-up

OWNER INFORMATION
Name:
DOB:
Gender:	Male Female
Age @ Death:

Spouse Living:	Yes No
Spouse Name:
Spouse DOB:
Age @ Death:

ACCOUNT INFORMATION
State of Issue:
Account is currently an:	IRA Roth IRA SEP IRA 401(k) 401(b) Corporate Pension Profit Sharing Plan
Account Value:
If Roth, first dollar invested when?
Has client taken this year's required minimum distribution yet?	Yes No
Term Length:	7 Year 10 Year 12 Year

BENEFICIARY INFORMATION
Children/Grandchild:
Age:
DOB:
Benefit Percentage*:

Children/Grandchild:
Age:
DOB:
Benefit Percentage*:

Children/Grandchild:
Age:
DOB:
Benefit Percentage*:

Children/Grandchild:
Age:
DOB:
Benefit Percentage*:

Children/Grandchild:
Age:
DOB:
Benefit Percentage*:

Children/Grandchild:
Age:
DOB:
Benefit Percentage*:

Children/Grandchild:
Age:
DOB:
Benefit Percentage*:

Children/Grandchild:
Age:
DOB:
Benefit Percentage*:
*Total for all beneficiaries listed must equal 100%
ADDITIONAL INFORMATION
Please list any additional comments or competition information that will assist us in properly preparing your quote.

Your request cannot be honored unless this form is completed.
Check this box to consent to our communications agreement. You must consent to our communications agreement to send this form. Click here to read the agreement.

Application Materials

Click here for online applications.

Contracting Materials

Click here for contracting materials.

Quotes

Click here for annuity and insurance quotes.