Insurance Alert 2014 03 NEW FIXED ANNUITY … Alert 2014 - 03.pdfAttached is the new Fixed Annuity Compliance form that ... need help filling out the form; please call me

***Insurance Alert 2014 – 03*** NEW FIXED ANNUITY COMPLIANCE FORM AND

UPDATED VARIABLE ANNUITY COMPLIANCE FORM

Attached is the new Fixed Annuity Compliance form that will be used for ALL fixed annuities. We no

longer have separate compliance forms for the fixed, indexed and SPIA annuities. A completed sample

form is also attached for your reference. If you have any questions or need help filling out the form;

please call me at 214-859-1762 or Mari Franco at 214-859-1720.

Also attached is an updated Variable Annuity Compliance form. We have removed the “Customer

Affiliations and Disclosures” section from the top of page 2 since this information is not required for

variable annuities. We also added “not applicable for qualified plans” next to Creditor Protection on page

3. While annuities do provide creditor protection; there is some overlap when the money is qualified and

the rules vary so we do not want this to be a reason for purchase for a qualified annuity.

If you have business already in process with the old forms we will continue to accept them for 30

days. Please begin to use the new forms which are updated on the web sites. Please destroy all blank

forms that have been printed out so they will not be used going forward.

Thank you,

Barb

barbpittman

Vice President, SWIA Insurance Operations Manager

(214) 859-1762

(214) 859-6004 (FAX)

[email protected]

Member: NYSE/FINRA/SIPC

mailto:[email protected]

Fixed Annuity Compliance Form (4/9/2014) 1

Southwest Insurance Agency 1201 Elm STREET, Suite 3500, Dallas, TEXAS 75270

Fixed Annuity Compliance Form

Select One: Individual Joint Trust Other Non-Natural Entity (Specify): ____________________________________________________ 1. Representative/ Product Information

Representative Name: _____________________________________________________ Rep #: ___________________ Branch #: ____________________ Insurance Company: _______________________________________________________ Product: ______________________________________________ Select One: Non-Qualified OR Qualified Select One: Fixed Indexed SPIA DIA 2. Annuitant/Applicant Information

Name of Contract Owner (First, Middle, Last) or Business/ Trust/ Entity Name Social Security #/ Tax ID # Date of Birth (Month/Day/Year)

Name of Joint Contract Owner (First, Middle, Last) (If applicable) Social Security #/ Tax ID # Date of Birth (Month/Day/Year)

Name of Annuitant (First, Middle, Last) Social Security #/ Tax ID # Date of Birth (Month/Day/Year)

3. Customer Identification

USA PATRIOT Act - Important Information About Opening A New Account To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means to you: When you open an account, we will require your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents. For Contract Owner: Driver’s License Passport/Visa Other Issuer:_______________________________________________________ ID Number: ___________________________________________ Date of Issuance (If applicable): ___________________________________ Date of Expiration (If applicable): __________________________ For Owner Co-Applicant (If applicable): Driver’s License Passport/Visa Other Issuer: ID Number: Date of Issuance (If applicable): Date of Expiration (If applicable): For Annuitant (if different from Owner): Driver’s License Passport/Visa Other Issuer: ID Number: Date of Issuance (If applicable):_____________________________________________ Date of Expiration (If applicable): _____________________

4. Customer Profile

Marital Status: Single Married Divorced Widowed Number of Dependents: _____________

Citizenship Status: U.S. Citizen Resident Alien Non-Resident Alien (If a Non-Resident Alien, you must provide a valid government-issued photo ID and a completed W-8BEN) Country of Citizenship if Non-U.S. : ________________________________________

Owner’s Employment Information (Please specify if self-employed, unemployed, retired, homemaker, student or other):

Employer (If self-employed or retired, specify type of business.) Occupation/Job Title Business Telephone

Employer’s Address City State/Province Country Zip Code For Entity Applicant (Must include copy of organizational document, appropriate trading authorization and Non-natural Person Form): Trust Agreement Articles of Incorporation Partnership Agreement Other _____________________________________


4. Customer Profile (continued)

Customer Investment Objectives and Risk Tolerance

Select the categories that best describe your investment objectives (and if joint that of any co-applicants) and the risk that you are willing to assume in this account. Different investment products and strategies involve different degrees of risk. The greater the expected returns of a product or strategy, the greater the risk that you could lose some or all of your investment. Investments should be chosen based on your objectives, timeframe, and tolerance for market fluctuations. (Note: a secondary investment objective is not required)

Select One Primary Investment Objective with Your Associated Risk Tolerance (Check one box only)

Select One Secondary Investment Objective with Your Associated Risk Tolerance (Check one box only)

Capital Preservation Low Income Low Moderate High Income Low Moderate High Growth Moderate High Growth Moderate High

Financial Information – Contract Owner Please check this box if for joint applicants you would like to combine your incomes and net worth:

Investment Experience (in Years) Stocks: ______ Bonds: ______ Mutual Funds: ______ Annuities: ______ Options: ______ Commodities: ______ Other (List): _________________ Annual Income Net Worth Liquid Net Worth Federal Tax Rate (%) $ ______________ $ _______________ $ _______________ ______________

Other Annuity Information: Variable or Fixed Insurance Company Amount of Annuity Qualified or Non-Qualified

$

$

$

$

Annual Expenses (Recurring)

Special Expenses

(Future/Non-Recurring)

What is your source of funds for this account (Check all that apply)

$50,000 and under $50,001-100,000 $100,001-250,000 $250,001-500,000 Over $500,000

Not Applicable (N/A) $50,000 and under $50,001-100,000 $100,001-250,000 Over $250,000

Income from Earnings Investments/Transfer from Brokerage Account 1035 Exchange or Qualified Transfer from Annuity or Life Insurance (fill out side by side comparison and include recent statement) Gift Sale of Business or Real Estate Inheritance Pension/401k Spouse/ Parent/ Relative Legal/ Insurance Settlement Matured CD

Mutual Funds* Other: _____________________________________________

*Use Long Term Investment Exchange Form for Mutual Funds

Investments in this account will be: (Check one)

Timeframe for Special Expenses

Less than 1/3 of my financial portfolio

Roughly 1/3 to 2/3 of my financial portfolio

More than 2/3 of my financial portfolio

Special Expense: _____________

Not Applicable (N/A) Within 2 years 3-5 years 6-10 years 11 years or more

Time Horizon - When will you use the annuity for your stated objective(s)?

Under 3 years 3-5 years 6-10 years 11-20 years Over 20 years

I plan to use this account for the following: (Check all that apply)

Retirement Income

Tax-deferred Growth (not applicable for qualified plans)

Death Benefit

Creditor Protection (not applicable for qualified plans)

Other:


5. Fixed Annuity Disclosures

PLEASE READ ALL OF THE DISCLOSURES BELOW. SIGN TO ACKNOWLEDGE YOU HAVE READ AND UNDERSTAND THEM.

I/We agree that this annuity is suitable for my insurance and financial objectives.

I/We understand fees/charges associated with this annuity have been explained.

I/We understand that renewal rates may decrease due to market fluctuations and company practices.

I/We understand a Federal income tax penalty of 10% may be imposed on withdrawals taken prior to age 59 1/2.

I/We understand that annuities placed in qualified plans do not add any tax-deferral benefits. I/We understand that earnings, when withdrawn, may be taxed as ordinary income. I/We understand that a limited number of insurance companies contribute to the cost of my broker dealer’s conferences and education for it’s representatives, which does not add any expense to my contract. This company: IS IS NOT one of those contributing insurance companies.

I/We: HAVE HAVE NOT had another exchange within the preceding 36 months. If I/we “have” had an exchange please provide the details of the exchange (i.e. date, policies, representative, company, etc.): ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ For SPIA Purchases: I understand that the format of the immediate annuity payments will be:

________________________________________________________________________________________________

My payments have been calculated (if fixed), and will be $_______________ per_____________________ I (circle one) AM / AM NOT foregoing my principal for the agreed periodic payments. For Indexed Annuity Purchases: I/We understand that the rate of return of this annuity can vary due to the specific crediting methods, participation rates, earnings caps and spreads, as well as performance of the indexes upon which this annuity is based. The method of crediting interest, participation rates and caps for my particular annuity has been explained to me in full.

INDEX CREDITING METHOD CAP RATE PARTICIPATION RATE

SPREAD % Allocated

--add to 100%---

= 100%

6. Customer Signature(s) I/WE HAVE READ AND UNDERSTAND THE DISCLOSURES LISTED ABOVE.

x _____________________________________ Contract Owner’s Signature Date

______________________________________ Contract Owner’s Printed Name

x _______________________________________ Joint Owner’s Signature Date

_______________________________________ Joint Owner’s Printed Name


Annuity Purchase Form

Complete “Proposed Policy” side for new money purchases. (Long Term Investment Exchange form required if source of funds are mutual funds)

Complete “Existing Policy and Proposed Policy” side by side comparison for exchanges/replacements. (Include recent statement of existing policy)

Existing Policy Proposed Policy Insurance Company Name:

Product Name:

Type of Contract: Fixed or Variable Annuity/Life policy

Issue Date:

Current Market Value (for existing product) New Estimated Market Value (proposed policy) $ $ (less surrender charges plus applicable bonus) Existing Policy Surrender Charges: $ $ N/A

Cash Surrender Value: $ $ N/A (market value less surrender charge)

Surrender Period Remaining A: Years A: A:

B: % by year B: B:

Guarantee Period & Fixed Interest Rate:

Death Benefit Value: $ $

List the death benefit that applies & cost: Cost Cost % %

% %

Living Benefit Value: $ $

List the living benefit and other features (i.e. bonus) that apply & their costs: % %

% %

% %

% %

TOTAL Annual Charges (%) to include M&E, Admin. and Features (excludes subaccount management expenses) Explain the client’s intentions for the annuity purchase, and for exchanges, how does the exchange benefit the client:

We have confirmed with the existing carrier that the additional benefits are not able to be added to the current contract.

Owner’s Initials ______ ______ Representative’s Initials ______ Owner Signature: Date:

Joint Owner Signature: Date:

Representative Signature: Date:


Non-Qualified Transfer of Funds

For a Non-Qualified transfer of funds from a Southwest Securities Account:

Please transfer $ ______________________________________ from Southwest Securities Account # ___________________________________

To (Insurance Company): __________________________________________ FBO: ___________________________________________

Owner Signature: X _____________________________________________________________ Date:_____________

Joint Owner Signature: X _________________________________________________________ Date:_____________

Representative Information

• Date you gave the privacy notice to the client:____/____/____

• Is the business being conducted in the client’s resident state? Yes No

• Is your license, for this type of business, current in the state of business? Yes No

• Are you appointed with this insurance company in the state of business? Yes No

• Are you satisfied this product, as purchased, is suitable for this client? Yes No

• If this annuity is owned by a non-natural person, have you had the client sign the appropriate form? Yes No N/A

• I have taken the product training required by the insurance carrier prior to selling this variable annuity. Yes No

Representative Signature: X_______________________________________________ Date: _______________

Branch Manager/ OSJ Suitability Review

• Does the broker have the appropriate state insurance license? Yes No

• Does the annuity create a potential liquidity problem(s) for the client during the surrender charge period? Yes No

• If yes, explain your approval: ______________________________________________________________

• In your judgment, is the client’s age suitable for the stated time horizon? Yes No

• Are the riders and options purchased consistent for the client’s goals and reasons given for the purchase of the annuity? Yes No

• Are the options (fixed or indexed) chosen consistent with the client’s investment objective? Yes No

If this is a replacement or exchange, review the previous contract’s statement:

• What are the surrender costs incurred by the client? $

• Do you agree with the reasoning and economics of the exchange or transfer? Yes No N/A

If this contract includes a bonus, are any additional charges or increased surrender periods appropriate for the client? Yes No N/A Branch Manager/ OSJ Printed Name: X___________________________________________________ Date: __________________

Branch Manager/ OSJ Signature: X_______________________________________________________ Date: __________________ SWIA Signature: X_____________________________________________________________________ Date: __________________


Southwest Insurance Agency 1201 Elm STREET, Suite 3500, Dallas, TEXAS 75270

Fixed Annuity Compliance Form

Select One: Individual Joint Trust Other Non-Natural Entity (Specify): ____________________________________________________ 1. Representative/ Product Information

Representative Name: _____________________________________________________ Rep #: ___________________ Branch #: ____________________ Insurance Company: _______________________________________________________ Product: ______________________________________________ Select One: Non-Qualified OR Qualified Select One: Fixed Indexed SPIA DIA 2. Annuitant/Applicant Information






4. Customer Profile







4. Customer Profile (continued)


Select the categories that best describe your investment objectives (and if joint that of any co-applicants) and the risk that you are willing to assume in this account. Different investment products and strategies involve different degrees of risk. The greater the expected returns of a product or strategy, the greater the risk that you could lose some or all of your investment. Investments should be chosen based on your objectives, timeframe, and tolerance for market fluctuations. (Note: a secondary investment objective is not required)



Capital Preservation Low Income Low Moderate High Income Low Moderate High Growth Moderate High Growth Moderate High

Financial Information – Contract Owner Please check this box if for joint applicants you would like to combine your incomes and net worth:

Investment Experience (in Years) Stocks: ______ Bonds: ______ Mutual Funds: ______ Annuities: ______ Options: ______ Commodities: ______ Other (List): _________________ Annual Income Net Worth Liquid Net Worth Federal Tax Rate (%) $ ______________ $ _______________ $ _______________ ______________

Other Annuity Information: Variable or Fixed Insurance Company Amount of Annuity Qualified or Non-Qualified

$

$

$

$

Annual Expenses (Recurring)

Special Expenses

(Future/Non-Recurring)

What is your source of funds for this account (Check all that apply)

$50,000 and under $50,001-100,000 $100,001-250,000 $250,001-500,000 Over $500,000


Income from Earnings Investments/Transfer from Brokerage Account 1035 Exchange or Qualified Transfer from Annuity or Life Insurance (fill out side by side comparison and include recent statement) Gift Sale of Business or Real Estate Inheritance Pension/401k Spouse/ Parent/ Relative Legal/ Insurance Settlement Matured CD

Mutual Funds* Other: _____________________________________________


Investments in this account will be: (Check one)



Roughly 1/3 to 2/3 of my financial portfolio


Special Expense: _____________


Time Horizon - When will you use the annuity for your stated objective(s)?

Under 3 years 3-5 years 6-10 years 11-20 years Over 20 years

I plan to use this account for the following: (Check all that apply)

Retirement Income


Death Benefit


Other:


5. Fixed Annuity Disclosures

PLEASE READ ALL OF THE DISCLOSURES BELOW. SIGN TO ACKNOWLEDGE YOU HAVE READ AND UNDERSTAND THEM.

I/We agree that this annuity is suitable for my insurance and financial objectives.

I/We understand fees/charges associated with this annuity have been explained.

I/We understand that renewal rates may decrease due to market fluctuations and company practices.

I/We understand a Federal income tax penalty of 10% may be imposed on withdrawals taken prior to age 59 1/2.

I/We understand that annuities placed in qualified plans do not add any tax-deferral benefits. I/We understand that earnings, when withdrawn, may be taxed as ordinary income. I/We understand that a limited number of insurance companies contribute to the cost of my broker dealer’s conferences and education for it’s representatives, which does not add any expense to my contract. This company: IS IS NOT one of those contributing insurance companies.

I/We: HAVE HAVE NOT had another exchange within the preceding 36 months. If I/we “have” had an exchange please provide the details of the exchange (i.e. date, policies, representative, company, etc.): ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ For SPIA Purchases: I understand that the format of the immediate annuity payments will be:

________________________________________________________________________________________________

My payments have been calculated (if fixed), and will be $_______________ per_____________________ I (circle one) AM / AM NOT foregoing my principal for the agreed periodic payments. For Indexed Annuity Purchases: I/We understand that the rate of return of this annuity can vary due to the specific crediting methods, participation rates, earnings caps and spreads, as well as performance of the indexes upon which this annuity is based. The method of crediting interest, participation rates and caps for my particular annuity has been explained to me in full.

INDEX CREDITING METHOD CAP RATE PARTICIPATION RATE

SPREAD % Allocated

--add to 100%---

= 100%

6. Customer Signature(s) I/WE HAVE READ AND UNDERSTAND THE DISCLOSURES LISTED ABOVE.

x _____________________________________ Contract Owner’s Signature Date


x _______________________________________ Joint Owner’s Signature Date

_______________________________________ Joint Owner’s Printed Name






Product Name:

Type of Contract: Fixed or Variable Annuity/Life policy

Issue Date:




B: % by year B: B:

Guarantee Period & Fixed Interest Rate:



% %



% %

% %

% %

TOTAL Annual Charges (%) to include M&E, Admin. and Features (excludes subaccount management expenses) Explain the client’s intentions for the annuity purchase, and for exchanges, how does the exchange benefit the client:










Owner Signature: X _____________________________________________________________ Date:_____________

Joint Owner Signature: X _________________________________________________________ Date:_____________








• I have taken the product training required by the insurance carrier prior to selling this variable annuity. Yes No

Representative Signature: X_______________________________________________ Date: _______________



• Does the annuity create a potential liquidity problem(s) for the client during the surrender charge period? Yes No



• Are the riders and options purchased consistent for the client’s goals and reasons given for the purchase of the annuity? Yes No

• Are the options (fixed or indexed) chosen consistent with the client’s investment objective? Yes No

If this is a replacement or exchange, review the previous contract’s statement:


• Do you agree with the reasoning and economics of the exchange or transfer? Yes No N/A

If this contract includes a bonus, are any additional charges or increased surrender periods appropriate for the client? Yes No N/A Branch Manager/ OSJ Printed Name: X___________________________________________________ Date: __________________


.

Variable Annuity Compliance (4/9/2014) 1

Southwest Insurance Agency 1201 Elm St., Suite #3500, Dallas, TX 75270

Variable Annuity Compliance Form

Select One: Individual Joint Trust Other Non-Natural Entity (Specify)__________________________________________ 1. Representative/ Product Information

Representative Name: ___________________________________________________________ Rep #: __________________________ Branch #: _______________________ Insurance Company: _______________________________________________________ Product: _________________________________________________________ Select One: Non-Qualified OR Qualified 2. Annuitant/ Applicant Information






4. Customer Profile








Select the categories that best describe your investment objectives (and if joint that of any co-applicants) and the risk that you are willing to assume in this account. Different investment products and strategies involve different degrees of risk. The greater the expected returns of a product or strategy, the greater the risk that you could lose some or all of your investment. Investments should be chosen based on y our objectives, timeframe, and tolerance for market fluctuations. (Note that a secondary investment objective is not required)



Income Low Moderate High Income Low Moderate High Growth Moderate High Growth Moderate High Speculation High Speculation High

Investment Objective Descriptions

• Income: The primary objective of the income strategy is to provide current income rather than the long-term growth of principal.

• Growth: The objective of the growth strategy is to increase the value of your investment over time while recognizing a high likelihood of volatility.

• Speculation: A speculative objective assumes a higher risk of loss in anticipation of potentially higher-than-average gains by taking advantage of expected

price changes. You recognize and are able to bear the full risk of the loss of some or all principal in such investments. Risk Tolerance Descriptions

• Low (Conservative): I want to preserve my initial principal in this account, with minimal risk, even if that means this account does not generate significant income or returns and may not keep pace with inflation.

• Moderate: I am willing to accept some risk to my initial principal and tolerate some volatility to seek higher returns, and understand I could lose a portion of the money invested.

• High (Aggressive): I am willing to accept high risk to my initial principal, including high volatility, to seek higher returns over time, and understand I could lose all or a substantial amount of the money invested.

Customer Financial Information

Financial Information – Contract Owner (Please check this box if for joint applicants you would like to combine your incomes and net worth: )

Investment Experience (Years) Stock ______ Bonds ______ Mutual Funds ______ Annuities ______ Options ______ Commodities ______ Other (List) ___________________________ Annual Income Net Worth Liquid Net Worth Federal Tax Rate ______________ _______________ _______________ ______________

Other Annuity Information

Variable or Fixed Insurance Company Amount of Annuity Qualified or Non-Qualified $

$

$

$

.


Additional Customer Information (Combine Information for Joint Accounts)

Annual Expenses4 (Recurring)

Special Expenses5

(Future/ Non-Recurring)

Description of Terms 1

Annual income includes income from sources such as employment, alimony, social security, investment income, etc. 2

Net worth is the value of your assets minus your liabilities. For purposes of this application, assets include stocks, bonds, mutual funds, other securities, bank accounts, and other personal property. Do not include your primary residence among your assets. For liabilities, include any outstanding loans, credit card balances, taxes, etc. Do not include your mortgage. 3

Liquid net worth is your net worth minus assets that cannot be converted quickly and easily into cash, such as real estate, business equity, personal property and automobiles, expected inheritances, assets earmarked for other purposes, and investments or accounts subject to substantial penalties if they were sold or if assets were withdrawn from them. 4

Annual expenses might include mortgage payments, rent, long-term debts, utilities, alimony or child support payments, etc. 5

Special expenses might include a home purchase, remodeling a home, a car purchase, education, medical expenses, etc.

$50,000 and under $50,001-100,000 $100,001-250,000 $250,001-500,000 Over $500,000


The investments in this account will be: (Check one)



Roughly 1/3 to 2/3 of my financial

portfolio


Special Expense:_______________


Time Horizon - When will you use the annuity for your stated objective(s)? Under 3 years 3-5 years 6-10 years 11-20 years Over 20 years

I plan to use this account for the following (Check all that apply) What is your source of funds for this account (Check all that apply)

Retirement Income


Death Benefit


Other:

Income from Earnings Investments/ Transfer from Brokerage Account 1035 Exchange or Qualified Transfer from Annuity or Life Insurance (fill out side by side comparison and include recent statement) Gift Sale of Business or Real Estate Inheritance Pension/401k Spouse/ Parent/ Relative Legal/ Insurance Settlement Matured CD

Mutual Funds * Other: ______________________________________________


5. Account Agreement

I received a prospectus on _____ / _____ / ______ for the variable contract and hereby acknowledge that my registered representative has discussed the above aspects of investing in the variable contract with me. I also acknowledge that the prospectus should be referred to for a more detailed explanation of the risks associated with this investment. I understand that this contract might not be appropriate for short-term investment needs. When/If I surrender the contract, I may receive less than I invested.

Arbitration Agreement: The customer agrees, and br oker agrees that all controversies which may arise between us concerning any transaction or the construction, performance, or breach of this or any other agreement between us pertaining to securities and other property, whether entered into prior, on or subsequent to the date hereof, shall be determined by arbitration. Any arbitration under this agreement shall be conducted pursuant to the Federal Arbitration Act before FINRA. The award of the arbitrators, or of the majority of them, shall be final, and judgment upon the award rendered may be entered in any court, state or federal, having jurisdiction. Further, no person shall bring putative or certified class action to arbitration, nor seek to enforce any pre-dispute arbitration agreement against any person who has initiated in court a putative class action until: (I) The class action is denied; (II) the class is decertified; or (III) the customer is excluded from the class by the court. Such forbearance to enforce an agreement to arbitrate shall not constitute a waiver of any rights under this agreement except to the extent herein.

Arbitration Disclosures: Arbitration is final and binding on the parties. The parties are waiving their right to seek remedies in court, including the right to jury trial. Pre-arbitration discovery is generally more limited than and different from court proceedings. The arbitrators’ award is not required to include factual findings or legal reasoning and the party’s right to appeal or seek modification of rulings by the arbitrators is strictly limited. The panel of arbitrators will typically include a minority of arbitrators who were or are affiliated with the securities industry.

6. Customer Signatures

x _____________________________________ _____________ Contract Owner’s Signature Date


x _______________________________________ _________________ Joint Owner’s Signature Date _______________________________________ Joint Owner’s Printed Name






Product Name:

Type of Contract: Fixed Annuity/Life /Variable/Mutual Fund

Issue Date:




B: % by year B: B:

Guarantee Period & Fixed Interest Rate: N/A



% %



% %

% %

% %

TOTAL Annual Charges (%) to include M&E, Admin. and Features (excludes subaccount management expenses) Explain the client’s intentions for the variable annuity purchase, and for exchanges, how does the exchange benefit the client:





.


Variable Annuity Disclosures

PLEASE READ ALL OF THE DISCLOSURES BELOW. SIGN TO ACKNOWLEDGE YOU HAVE READ AND UNDERSTAND THEM. (For Joint Owners, both Signatures are Required)

I agree that a variable annuity is suitable for my insurance and financial objectives.

Fees/charges associated with the annuity have been explained to me.

I understand that values may increase and decrease due to market fluctuation because yields and returns of the variable subaccounts are not guaranteed.

A Federal income tax penalty of 10% may be imposed on withdrawals taken prior to age 59 1/2.

I understand that annuities placed in qualified plans do not add any tax-deferral benefits.

I understand that a limited number of insurance companies contribute to the cost of my broker dealer’s conferences and education for it’s

representatives, which does not add any expense to my contract. This company IS IS NOT one of those contributing insurance companies.

I HAVE HAVE NOT had another exchange within the preceding 36 months. If I “have” had an exchange please provide the details of the

exchange (i.e. date, policies, representative, company, etc.):_______________________________________________________________________

_______________________________________________________________________________________________________________________

I HAVE READ AND UNDERSTAND THE DISCLOSURES LISTED ABOVE:

Owner Signature: X______________________________________________________ Date:_____________

Joint Owner Signature: X_________________________________________________ Date:_____________





Owner Signature: X _____________________________________________________________ Date:_____________ Joint Owner Signature: X _________________________________________________________ Date:_____________



• Did you deliver the required prospectuses prior to discussing the Product? Yes No






• I have taken the product training required by the insurance carrier prior to selling this variable annuity. Yes No Representative Signature: X _______________________________________________ Date: _______________



• Does the VA create a potential liquidity problem(s) for the client during the surrender charge period? Yes No



• Are the riders and options purchased consistent for the client’s goals and reasons given for the purchase of the VA? Yes No

• Are the investment options (fixed and variable) chosen consistent with the client’s investment objective? Yes No If this is a replacement or exchange, review the previous contract’s statement:


• Do you agree with the reasoning and economics of the exchange or transfer? Yes No N/A If this contract includes a bonus, are any additional charges or increased surrender periods appropriate for the client? Yes No N/A Branch Manager/ OSJ Printed Name: X___________________________________________________ Date: __________________


Documents

***Insurance Alert 2014 03*** NEW FIXED ANNUITY … Alert 2014 - 03.pdfAttached is the new Fixed Annuity Compliance form that ... need help filling out the form; please call me

Insurance Alert 2014 03 NEW FIXED ANNUITY … Alert 2014 - 03.pdfAttached is the new Fixed Annuity Compliance form that ... need help filling out the form; please call me