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- Our Team
Whole Life Lessons
Our Services
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Contact Us

IBC GLOBAL – ANNUITY QUESTIONNAIRE

(Please answer ALL sections completely)

Step 1 of 7

14%

Basic Information
Full legal name
First Middle Last Suffix
Place of birth
State / Province / Region Country
Marital status
- Married
- Single
- Divorced
- Widowed
- Separated
Date of birth
MM slash DD slash YYYY
Social security number
Primary residence address
Street Address City State / Province / Region ZIP / Postal Code Country
How many years at present address?
Please only type the number of years
If under 2 years, previous address
Street Address City State / Province / Region ZIP / Postal Code Country
Preferred phone number
Input numbers only example: 123-456-7890
Preferred email address
Driver’s license number and state
Front of Driver’s License
Accepted file types: jpeg, png, pdf, Max. file size: 5 MB.
Back of Driver’s License
Accepted file types: jpeg, png, pdf, Max. file size: 5 MB.
US citizen?
- Yes
- No
VISA # and exp Date if NO to US citizen
Have you applied for any insurance within the past 12 months?
- Yes
- No
Name of the insurance carrier
Amount applied for
Outcome of application
- Approved
- Denied
- Discontinued
Do you have current Life Insurance in force?
- Yes
- No
Please list any in force policies below including the company, amount of coverage, year issued, and type of insurance
Are you replacing any existing insurance policies?
- Yes
- No
Please specify which policy you are replacing (provide the policy number as well, if possible)

Employer Information
Enter employer’s name (or “Retired,” “Student,” or “Homemaker”)
Employer’s address
Street Address City State / Province / Region ZIP / Postal Code Country

If Retired/Student/Homemaker, enter your home address
Nature of business
Job title
How years at current employer?
Please only type the number of years
If under 2 years, previous employer’s name
If under 2 years, previous employer’s address
Street Address City State / Province / Region ZIP / Postal Code Country

Income
Source(s) of Income
- Salary/Wages
- Pension/Retirement
- Social Security
- Disability
- Investment Income
- Rental Income
- Trust Income
- Other
Other Source(s) of Income
Monthly Individual Income (Net after taxes)
Monthly Individual Expenses
Monthly Household Income (Net after taxes)
Monthly Household Expenses:

Financial Details
Annual Earned Income (Salary, Tips, Commissions, Other Income)
Annual Unearned Income (Interest from Stocks, Bonds, Investments, Rents, etc.)
Liquid Assets
- Cash/Checking/Savings
- CDs
- Money Market/Brokerage Account
- Stocks/Bonds
- Mutual Funds (except Class B)
- Annuities (out of surrender period)
- Cash Value of Life Insurance (out of surrender period)
- Pension/401K
Cash/Checking/Savings Amount
CDs Amount
Money Market/Brokerage Account Amount
Stocks/Bonds Amount
Mutual Funds (except Class B) Amount
Annuities (out of surrender period) Amount
Cash Value of Life Insurance (out of surrender period) Amount
Pension/401K Amount
Non-Liquid Assets
- Value of Home
- Other Real Estate
- Annuities (in surrender period)
- Other Valuable Personal Property (Gold, Collectibles, etc.)
- Cash Value of Life Insurance (in surrender period)
- Class B Mutual Funds (w/ deferred sales charges)
- Pension/401K (if under 59 1/2)
Value of Home
Value of other Real Estate
Value of Annuities (in surrender period)
Value of Other Valuable Personal Property (Gold, Collectibles, etc.)
Value of Cash Value of Life Insurance (out of surrender period)
Value of Class B Mutual Funds (w/ deferred sales charges)
Value of Pension/401K (if under 59 1/2)
Short Term Liabilities
Long Term Liabilities

Annuity Funding Sources
Please select the source(s) of funding for your annuity
- Cash/Checking/Savings
- Stocks/Bonds
- CDs
- Reverse Mortgage/Home Equity Loan
- Money Market/Brokerage Account
- Inheritance/Death Claim Proceeds/Gift
- Mutual Funds (except Class B with deferred sales charges)
- Class B Mutual Funds (with deferred sales charges)
- Annuities (out of surrender period)
- Annuities (in surrender period)
- Cash Value of Life Insurance (out of surrender period)
- Cash Value of Life Insurance (in surrender period)
- Lump Sum Pension Distribution (defined benefit)
- Other
Amount of Cash/Checking/Savings
Amount of Stocks/Bonds
Amount of CDs
Amount of Reverse Mortgage/Home Equity Loan
Amount of Money Market/Brokerage Account
Amount of Inheritance/Death Claim Proceeds/Gift
Amount of Mutual Funds (except Class B with deferred sales charges)
Amount of Class B Mutual Funds (with deferred sales charges)
Amount of Annuities (out of surrender period)
Amount of Annuities (in surrender period)
Amount of Cash Value of Life Insurance (out of surrender period)
Amount of Cash Value of Life Insurance (in surrender period)
Amount of Lump Sum Pension Distribution (defined benefit)
Please specify other source
Amount of Other Source

Primary Beneficiary
Primary beneficiary name
First Middle Last Suffix
Primary beneficiary date of birth
MM slash DD slash YYYY
Primary beneficiary address
Street Address City State / Province / Region ZIP / Postal Code Country
Primary beneficiary relationship to you

Secondary Beneficiary
Secondary beneficiary name
First Middle Last Suffix
Secondary beneficiary date of birth
MM slash DD slash YYYY
Secondary beneficiary address
Street Address City State / Province / Region ZIP / Postal Code Country
Secondary beneficiary relationship to you
* If you have more than one primary and/or secondary beneficiary, please list below and specify percentages for each. Beneficiaries can be changed/added at any time during and after the application process.
Additional beneficiaries
Additional comments
Name of your IBC Global Agent
If you do not see your agent above, please specify below
If you have any questions please call us at 610-681-2655.

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Kresgeville, Pennsylvania 18333

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