Attachment N - Annuity Bid Form Example.doc

This is an Annuity Bid Form example prepared by the Massachusetts State Lottery Commission in response to RFQ 2602 for lifetime annuity bids. The form serves as a template for qualified insurance companies to submit bids for providing lifetime annuitized premiums to lottery prize winners. The example form demonstrates the required submission format and information fields necessary for bidders to participate in the Massachusetts State Lottery Commission's Lifetime Annuity RFR LOT 2109 #7.

The bid form requests premium cost quotations for two sample $100 weekly lifetime annuity prizes: one for Jessica M. Wood (female, born 12/9/1987, prize amount $5,200, anniversary date 3/3/2026) and one for Christine A. Miller (female, born 8/12/1951, prize amount $5,200, anniversary date 3/6/2026). Bidders must complete the form by entering the premium costs for each annuitant and providing firm identification information, including company name, address, contact person, telephone number, authorized signature, and submission date. The form establishes the standard documentation and pricing structure that qualified insurance companies must use when submitting their lifetime annuity bids to the Massachusetts State Lottery Commission.