Mississippi Administrative Code › Title 19 - Department of Insurance › Part 2 - Life Insurance › Chapter 18 - Suitability in Annuity Transactions Regulation › Appendix A

Current through June 25, 2024
INSURANCE AGENT (PRODUCER) DISCLOSURE FOR ANNUITIES
Do Not Sign Unless You Have Read and Understand the Information
				  in this Form
Date: ________________________
I.
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 MS:
				  ________________________________________________
II.
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 noninsurance
				  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
Miss. Code
				  Ann. §§
										83-5-29 to  83-5-51 (Rev.
				  2011)