FORM 1
INSURANCE AGENT (PRODUCER) DISCLOSURE FOR ANNUITIES Do Not Sign Unless You Have Read and Understand the Information in this Form
Date: _________________________
INSURANCE AGENT (PRODUCER) INFORMATION ("Me", "I", "My")
First Name:______________________ Last Name:______________________
Business or Agency Name:______________________ Website:__________________
Business Mailing Address: _______________________________________________
Business Telephone Number:______________________
Electronic Mail Address:_____
National Producer Number in Alaska:__
CUSTOMER INFORMATION ("You", "Your")
First Name:______________________ Last Name:______________________
What Types of Products Can I Sell You?
I am licensed to sell annuities to You in accordance with state law. If I recommend that You buy an annuity, it means 1 believe that it effectively meets Your financial situation, insurance needs, and financial objectives. Other financial products, such as life insurance or stocks, bonds, and mutual funds, also may meet Your needs. I offer the following products:
______Fixed or Fixed Indexed Annuities
_______Variable Annuities
_______Life Insurance
I need a separate license to provide advice about or to sell non-insurance financial products. I have checked below any non-insurance financial products that I am licensed and authorized to provide advice about or to sell.
______Mutual Funds
______Stocks/Bonds
_______Certificates of Deposits
Whose Annuities Can I Sell to You? I am authorized to sell:
_______Annuities from only One Insurer
______Annuities from Two or More Insurers
_______Annuities from Two or More Insurers although I primarily sell annuities from:
How I'm Paid for My Work:
It's important for You to understand how I'm paid for my work.
Depending on the particular annuity You purchase, I may be paid a commission or a fee.
Commissions are generally paid to Me by the insurance company while fees are generally paid to Me by the consumer. If You have questions about how I'm paid, please ask Me.
Depending on the particular annuity You buy, I will or may be paid cash compensation as follows:
_______ Commission, which is usually paid by the insurance company or other sources, describe:
_______
Fees (such as a fixed amount, an hourly rate, or a percentage of your payment), which are usually paid directly by the customer.
_______Other (Describe):________________________________________________________
If You have questions about the above compensation 1 will be paid for this transaction, please ask me.
I may also receive other indirect compensation resulting from this transaction (sometimes called "non-cash" compensation), such as health or retirement benefits, office rent and support, or other incentives from the insurance company or other sources. By signing below. You acknowledge that You have read and understand the information provided to You in this document.
_______________
Customer Signature
________________
Date
________________
Agent (Producer) Signature
FORM 2
CONSUMER REFUSAL TO PROVIDE INFORMATION Do Not Sign Unless You Have Read and Understand the Information in this Form.
Why are You being given this form?
You are buying a financial product-an annuity. To recommend a product that effectively meets Your needs, objectives and situation, the agent broker, or company needs information about You, Your financial situation. Insurance needs and financial objectives.
If you sign this form, it means You have not given the agent, broker, or company some or all the information needed to decide if the annuity effectively meets Your needs, objectives, and situation. You may lose protections under the Insurance Code of Alaska if You sign this form or provide inaccurate information.
Statement of Purchaser:
___________I refuse to provide this information at this time.
__________I have chosen to provide LIMITED information at this time.
___________
Customer Signature
____________
Date
and
FORM 3
Consumer Decision to Purchase an Annuity NOT Based on a Recommendation. Do Not Sign This Form Unless You Have Read and Understand It.
Why are You being given this form?
You are buying a financial product-an annuity.
To recommend a product that effectively meets your needs, objectives and situation, the agent, broker, or company has the responsibility to learn about You, your financial situation. Insurance needs and financial objectives.
If you sign this form, it means You know that you're buying an annuity that was not recommended.
Statement of Purchaser:
I understand that I am buying an annuity, but the agent, broker, or company did not recommend that I buy it. If I buy it without a recommendation, I understand I may lose protections under the Insurance Code of Alaska.
_____________
Customer Signature
_____________
Date
_____________
Agent/Producer
_____________
Signature
_____________
Date
3 AAC 26.775
Authority:AS 21.06.090
AS 21.36.020
AS 21.36.030
AS 21.36.040
AS 21.36.050
AS 21.36.900