La. Admin. Code tit. 37 § XIII-11721
APPENDIX A
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\Agency Name: Website:
Business Mailing Address:
Business Telephone Number:
Email Address:
National Producer Number in [state]:
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 I 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 (1) 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 Yo u 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 You. 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. If other sources, describe:
Fees (such as a fixed amount, an hourly rate, or a percentage of your payment), are usually paid directly by the customer. Other (Describe):
If you have questions about the above compensation I 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.
Drafting Note:This disclosure may be adapted to fit the particular business model of the producer. As an example, if the producer only receives commission or only receives a fee from the consumer, the disclosure may be refined to fit that particular situation. This form is intended to provide an example of how to communicate producer compensation, but compliance with the regulation may also be achieved with a more precise disclosure, including a written consulting, advising, or financial planning agreement.
Drafting Note:The acknowledgement and signature should be in immediate proximity to the disclosure language.
By signing below, Yo u acknowledge that Yo u have read and understand the information provided to You in this document.
Customer Signature
Date
Agent (Producer) Signature
Date
APPENDIX B
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're 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 [this state] 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
APPENDIX C
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 [this state].
Customer Signature
Date
Agent/Producer Signature
Date
La. Admin. Code tit. 37, § XIII-11721