Ga. Comp. R. & Regs. 120-2-94- app (120-2-94) C
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 [this state].
____________________________
Customer Signature
____________________________
Date
____________________________
Agent/Producer Signature
____________________________
Date
Ga. Comp. R. & Regs. R. 120-2-94- app (120-2-94) C