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Allstate Insurance - Northbrook Illinois - DOC

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					                  ALLSTATE LIFE INSURANCE COMPANY
                 Home Office: Northbrook, Illinois 60062
            Application for Single Premium Immediate Annuity

 1. Measuring Life
  Full Name: ______________________________                       Phone: _________
  Address: ______________________________________________
    Social Security No: ____________ Date of Birth: ________ Sex: ___________

 2. Joint Measuring Life (if applicable)
  Full Name: ______________________________                       Phone: _________
  Address: ______________________________________________
    Social Security No: ____________ Date of Birth: ________ Sex: ___________
    Relationship to Measuring Life: _________________

 3. Owner
     Full Name: _________________                                Phone: _________
     Address: _________________

 4. Payee (will be Measuring Life if left blank)
  Full Name: ______________________________                               Phone: _________
  Address: ______________________________________________
  Relationship to Measuring Life: _________________

 5. Payment Information (Submit proof of age for life or joint life payments.)
       Start Date Type (e.g., certain,    Amount           Number of       Frequency of
                    life, lump sum,                        Payments          Payments
                           joint)




 6. Beneficiary (will be Estate of Measuring Life if left blank)
  Full Name: ______________________________                              Phone: _________
  Address: ______________________________________________
    Social Security No: ____________       Relationship to Measuring Life: __________

 7. Premium $ 1 + valuable consideration

The Applicant represents that all statements and answers on this Application are true to the
best of his or her knowledge and belief and completely recorded herein.

Applicant: _________________         by __________________         Date __________
                Owner                        Signature & Title
LR877

				
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