Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-94 - SUITABILITY IN ANNUITY TRANSACTIONS › Appendix (120-2-94) A - INSURANCE AGENT (PRODUCER) DISCLOSURE FOR ANNUITIES

Current through Rules and Regulations filed through June 27, 2024
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 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. If 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 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.
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
_________________________________
Date