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Annuity Quote Request Form

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Financial Advisor Name*
Allowed to Sell Indexed Annuities?

ANNUITANT INFORMATION

Annuitant Name
Gender

ANNUITY DESIGN

Tax Qualified
Annuity Type
Design
Fixed Annuity Term (Years)

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CA Corp. Insurance License: 0E02059

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 Mailing & Overnight Address

CPS Advantage
6444 E. Spring Street #287
Long Beach, CA 90815

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