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?

YesNo
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

Checking/Savings/Money Market or CD1035 ExchangeRollover from Qualified Plan (401k,403b,457,Profit Sharing Plan, etc.)Liquidation/Surrender (of an Annuity, Life Insurance or Mutual Fund)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?

YesNo
Amount
Start Date

MonthDayYear
Frequency
Time Horizon of Portfolio (until depleted)

Short Term (1-4 Years)Intermediate (5-9 Years)Long-Term (10+ Years)
Select Most Appropriate Account Type

QualifiedNon-QualifiedTrust
Tax Rates to be Assumed
Federal
State
Most Appropriate Portfolio Risk Tolerance*:

ConservativeModerateGrowth
Goals & Objectives of the Annuity

Guaranteed IncomeFee ConsciousTax-Deferred Wealth AccumulationEstate PlanningOther (Explain Below)
Lincoln IRA Annuity Available Solutions
Select a Solution
Investor Advantage® Variable Annuity

ActivePassive
IA - Risk Tolerance

Conservative 30/70Moderate 65/35Growth 85/15Growth 100/0
Select desired benefits/riders if applicable

i4LIFE® AdvantageEarnings Optimizer Death Benefit
InvestmentSolutions℠ Variable Annuity

ActivePassive
IS - Risk Tolerance

Conservative 30/70Moderate 65/35Growth 85/15Growth 100/0
Select desired benefits/riders if applicable

Lincoln Market Select AdvantageLincoln Lifetime Income Advantage 2.0 (Only Available in Conservative or Moderate Model)Lincoln Max 6 Select Advantage4LATER Select Advantagei4LIFE® Advantagei4LIFE® Advantage Select Guaranteed Income BenefitHighest Anniversary Death Benefit
American Legacy® Target Date Income Variable Annuity
Select desired benefits/riders if applicable

Target Date Income Benefit
Level Advantage® Indexed Variable Annuity
Select desired benefits/riders if applicable

Guarantee of Principal Death Benefiti4LIFE® Indexed Advantage
Account Options

1-Year Indexed Accounts with Performance Cap1-Year Indexed Accounts with Performance Trigger3-Year Indexed Accounts with Participation Rate6-Year Indexed Accounts with Performance Cap6-Year Annual Lock Indexed Accounts with Performance Cap
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 Level15% Protection Level20% Protection Level
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 Level15% Protection Level
10% Protection Level - Allocation
ex. 50%
15% Protection Level - Allocation
ex. 50%
Nasdaq-100 Index®

15% Protection Level
15% Protection Level - Allocation
ex. 50%
Russell 2000® Index

10% Protection Level
10% Protection Level - Allocation
ex. 50%
MSCI EAFE Index

10% Protection Level
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 Level15% Protection Level
10% Protection Level - Allocation
ex. 50%
15% Protection Level - Allocation
ex. 50%
First Trust American Leadership Index™

10% Protection Level
10% Protection Level - Allocation
ex. 50%
Nasdaq-100 Index®

15% Protection Level
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
10% Protection Level - Allocation
ex. 50%
First Trust American Leadership Index™

10% Protection Level
10% Protection Level - Allocation
ex. 50%
Capital Strength Index℠

10% Protection Level
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 Level20% Protection Level30% Protection Level
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 Level20% Protection Level
10% Protection Level - Allocation
ex. 50%
20% Protection Level - Allocation
ex. 50%
Capital Strength Index℠

10% Protection Level20% Protection Level
10% Protection Level - Allocation
ex. 50%
20% Protection Level - Allocation
ex. 50%
Russell 2000® Index

10% Protection Level20% Protection Level30% Protection Level
10% Protection Level - Allocation
ex. 50%
20% Protection Level - Allocation
ex. 50%
30% Protection Level - Allocation
ex. 50%
MSCI EAFE Index

10% Protection Level
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
10% Protection Level - Allocation
ex. 50%
Russell 2000® Index

10% Protection Level
10% Protection Level - Allocation
ex. 50%
Capital Strength Index℠

10% Protection Level
10% Protection Level - Allocation
ex. 50%
MSCI EAFE Index

10% Protection Level
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