Plan Participant

GRIP RETIREMENT^SM, LLC

Plan Participant
A Guaranteed Retirement Income Program for pension and qualified rollovers.

GRIP Retirement Immediate Income Quote Requests
Client health factors? Click for underwritten - rated age income information!

Participant Information:
Name: Male Female
D.O.B. Age: State:

Joint (spouse) Participant Information (if any):
Name: Male Female
D.O.B: Age: State:

Source of Funds:
Qualified (Ira, 401K rollover, Pension etc.)
Non- Qualified (cash, 1035 exchange etc.)

Deposit Amount: $
Desired Income: $
1035 Cost Basis $

Deposit Date: Month Day Year

Income Start: Month Day Year

Annuity Payment Frequency:
Monthly Semi-Annually Quarterly Annually

Type of Guaranteed Income Annuity: (Multiple selection are allowed)
SINGLE LIFE
Life Only
Life with period certain of:
5 Year 10 Years 15 Years 20 Years
Specific: and Months
Life With Installment Refund
Life With Cash Refund (low availability on cash refunds, not offered by many companies)

Joint Lives
Joint & Survivor Lives ONLY
Joint with period certain of:
5 Year 10 Years 15 Years 20 Years
Specific: and
Joint Percent
Reduce on primary (default)
Reduce on either

Period Certain ONLY
Period Certain Only for:
5 Year 10 Years 15 Years 20 Years
Specific: Years and Months

Annual Increases:

Requested By:

Company You Work For:

Who is your company's plan provider:

Email: required

Phone: Appreciated

Fax: If you would like quotes faxed

Receive quotes by:
Email Adobe Acrobat PDF
Email Text
Fax
Phone Call
HTML Email Link

Please use this section for any special requests that do not appear on the form.
Additional - Referred By:

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Send mail to annuity@earthlink.net with questions or comments about this web site. Copyright © 2005 GRIP Retirement LLC Last modified: 04/08/08

Send mail to annuity@earthlink.net with questions or comments about this web site.
Copyright © 2005 GRIP Retirement LLC
Last modified: 04/08/08