Fee-Based Annuity Proposal Request Form

Fee-Based Annuity Proposal Request Form
New or Existing Submission
Please submit completed form and CURRENT STATEMENT to proposals@vicuscapital.com or fax to (814) 235-3500.
Date of Request

MonthDayYear
Requested Delivery Date

MonthDayYear
Client Name(s)
State of Residency
Annuitant Name(s)
Account Registration Name
Is this a Current Client of Yours?
Client(s) Age(s)
Advisor Name(s)
Advisor(s) Email Address
example@example.com
Value of Assets to be Placed in Annuity
Percentage of Total Client Net Worth Represented
Source of Funds

Other
If a 1035 Exhange or Liquidation/Surrender is Selected Above, Please Provide the Following, if Available:
Current Plan Provider Name
Current Product Type (MF, VA, 401k, etc.)
Current Contract/Account Value
Issue Date of Contract or Account Inception

MonthDayYear
Surrender Cost/Fees (attach schedule if available)
Type of Benefit Riders (if applicable)
Annual Cost of Benefit Riders (if applicable)
Additional Rider Details (if applicable)
Please provide a current statement if available
Current Statement

Cancelof
Income Needed?
Amount
Start Date

MonthDayYear
Frequency
Time Horizon of Portfolio (until depleted)
Select Most Appropriate Account Type
Tax Rates to be Assumed
Federal
State
Most Appropriate Portfolio Risk Tolerance*:
Goals & Objectives of the Annuity

Other (Explain Below)
Lincoln IRA Annuity Available Solutions
Select a Solution
Investor Advantage® Variable Annuity
IA - Risk Tolerance
Select desired benefits/riders if applicable
InvestmentSolutions℠ Variable Annuity
IS - Risk Tolerance
Select desired benefits/riders if applicable
American Legacy® Target Date Income Variable Annuity
Select desired benefits/riders if applicable
Level Advantage® Indexed Variable Annuity
Select desired benefits/riders if applicable
Account Options
1-Year Indexed Accounts with Performance Cap

Select a Market Index Option, a Protection Option, and Provide the Percentage of Allocation for Each Selection
S&P 500® Index
10% Protection Level - Allocation
ex. 50%
15% Protection Level - Allocation
ex. 50%
20% Protection Level-Allocation
ex. 50%
First Trust American Leadership Index™
10% Protection Level - Allocation
ex. 50%
15% Protection Level - Allocation
ex. 50%
Nasdaq-100 Index®
15% Protection Level - Allocation
ex. 50%
Russell 2000® Index
10% Protection Level - Allocation
ex. 50%
MSCI EAFE Index
10% Protection Level - Allocation
ex. 50%
1-Year Indexed Accounts with Performance Trigger

Select a Market Index Option, a Protection Option, and Provide the Percentage of Allocation for Each Selection
S&P 500® Index
10% Protection Level - Allocation
ex. 50%
15% Protection Level - Allocation
ex. 50%
20% Protection Level - Allocation
ex. 50%
First Trust American Leadership Index™
10% Protection Level - Allocation
ex. 50%
Nasdaq-100 Index®
15% Protection Level - Allocation
ex. 50%
3-Year Indexed Accounts with Participation Rate

Select a Market Index Option, a Protection Option, and Provide the Percentage of Allocation for Each Selection
S&P 500® Index
10% Protection Level - Allocation
ex. 50%
First Trust American Leadership Index™
10% Protection Level - Allocation
ex. 50%
Capital Strength Index℠
10% Protection Level - Allocation
ex. 50%
6-Year Indexed Accounts with Performance Cap

Select a Market Index Option, a Protection Option, and Provide the Percentage of Allocation for Each Selection
S&P 500® Index
10% Protection Level - Allocation
ex. 50%
20% Protection Level - Allocation
ex. 50%
30% Protection Level-Allocation
ex. 50%
First Trust American Leadership Index™
10% Protection Level - Allocation
ex. 50%
20% Protection Level - Allocation
ex. 50%
Capital Strength Index℠
10% Protection Level - Allocation
ex. 50%
20% Protection Level - Allocation
ex. 50%
Russell 2000® Index
10% Protection Level - Allocation
ex. 50%
20% Protection Level - Allocation
ex. 50%
30% Protection Level - Allocation
ex. 50%
MSCI EAFE Index
10% Protection Level - Allocation
ex. 50%
6-Year Annual Lock Indexed Accounts with Performance Cap

Select a Market Index Option, a Protection Option, and Provide the Percentage of Allocation for Each Selection
S&P 500® Index
10% Protection Level - Allocation
ex. 50%
Russell 2000® Index
10% Protection Level - Allocation
ex. 50%
Capital Strength Index℠
10% Protection Level - Allocation
ex. 50%
MSCI EAFE Index
10% Protection Level - Allocation
ex. 50%
Deliver RFP Confirmation to (email):
example@example.com
Upon clicking submit, a PDF copy of the Fee-Based Annuity RFP will be sent to the Sales and Marketing Team at Vicus Capital. A PDF copy of the request will also be provided to the email entered into the "Deliver RFP Confirmation to:" field.
Should be Empty:

Fee-Based Annuity Proposal Request Form

Lincoln IRA Annuity Available Solutions

1-Year Indexed Accounts with Performance Cap

1-Year Indexed Accounts with Performance Trigger

3-Year Indexed Accounts with Participation Rate

6-Year Indexed Accounts with Performance Cap

6-Year Annual Lock Indexed Accounts with Performance Cap