WorkingAmericanBenefits™

                                                                          
Product Selection:

       ANNUITIES                                                    Company                                   Initial Premium

    Fixed Annuity                        Select ALLIANZ Life Insurance Company American Equity Investment Life Insurance Co. Americo Financial Life and Annuity Ins. Co. Allstate Financial - AH Life Ins.Co. Illinois Mutual Life Insurance Company American Fidelity Assurance/AFAmerilife Div. CHASE Insurance Company Assurity Life Insurance Company    

    Fixed Index Annuity              Select ALLIANZ Life Insurance Company American Equity Investment Life Insurance Co. Americo Financial Life and Annuity Ins. Co. Allstate Financial - AH Life Ins.Co. Illinois Mutual Life Insurance Company    

    Variable Annuity                      Select ALLIANZ Life Insurance Company Allstate Financial/Allstate Insurance Company Illinois Mutual Life Insurance Company    

  Annuity Owner's Information: (Required)

First Name:       *          MI:            Last Name: *    

Street Address *     Apt. or Suite No.:     

City:                    *           State:*   - AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY           Zip Code: * 

Last 4 of Soc Sec No.:*   Home Phone.:*     Other Phone: 

E-mail Address:*   

Joint Owner's Information:  

First Name:                  MI:            Last Name:     

Street Address:      Apt. or Suite No.:     

City:                                 State:   - AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY           Zip Code:  

Last 4 Soc Sec No.:    Home Phone.:     Other Phone: 

Person to be insured Information: 

Note: Enter all that applies.

Annuitant: (Required)

First Name:       *          MI:            Last Name: *    

Street Address *     Apt. or Suite No.:     

City:                    *           State:*   - AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY           Zip Code: * 

Relationship:    * Select Self/Employee Spouse Dependent Other   Date Of Birth:*  Month 01 02 03 04 05 06 07 08 09 10 11 12 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1045 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920   Male   Female

Last 4 of Soc Sec No.:*   Home Phone.:*     Other Phone: 

Primary Beneficiary:*   Age:*   Relationship:* Select All Children Equally Aunt Brother Cousin Daughter Father Fiance Friend Granddaughter Grandfather Grandmother Grandson Legal Dependent Mother Nephew Niece Sister Son Spouse Uncle Other

Contingent Bene.:       Age:     Relationship:  Select All Children Equally Aunt Brother Cousin Daughter Father Fiance Friend Granddaughter Grandfather Grandmother Grandson Legal Dependent Mother Nephew Niece Sister Son Spouse Uncle Other

IMPORTANT!                IMPORTANT!

If you were told about this website by an agent, please enter the agent's name and agent number (If known) in the space below.  This information may be found on the agent's business card or on a flyer or correspondence given to you by the agent:

Agent's Name:        Agent Number: 

Congratulations!  You have now completed your pre-application for an annuity.  Please click on  the SUBMIT button below to submit your pre-application for processing.   Please check your e-mail at the e-mail address you provided above for confirmation of the receipt of your pre-application.  You will also be contacted by a professional insurance agent.   Your agent  will discuss the annuity with you before completing and mailing you the Annuity Application for your signature as well as any additional information needed to complete the sale.  If you are not contacted within a reasonable amount of time, please call us immediately at (954)430-8475 or send us an e-mail at customer_service@workingamericanbenefits.com.