New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 9 - LIFE INSURANCE AND ANNUITIES › Part 20 - SUITABILITY IN ANNUITY TRANSACTIONS › Appendix A - CONSUMER DISCLOSURE

Current through Register Vol. 35, No. 13, July 16, 2024
CONSUMER INFORMATION
First Name: _____________________________________ Last Name:
				  ____________________________________
INSURANCE PRODUCER INFORMATION
First Name: _____________________________________ Last Name:
				  ____________________________________
Business/Agency Name:
				  ________________________________________ Website:
				  _________________________
Business/Mailing Address:
				  _______________________________________________________________________
Business Telephone Number: ____________________________ Email
				  Address: ____________________________
National Producer Number ("NPN") ____________________________
				  Domicile State: ______________________
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 may also 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. Below, I have checked any non-insurance
				  financial products that I am licensed and authorized to provide advice about or
				  to sell.
Mutual Funds
Stocks/Bonds
Certificates of Deposit
Whose Annuities Can I Sell to You?
I am authorized to sell:
Annuities from only one insurer
Annuities from two or more insurers
Annuities from two or more insurers, although I primarily
				  sell annuities from: _______________________
How I am Paid for My Work?
It is important for You to understand how I am 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 insurer while
				  fees are generally paid to Me by the Consumer (You). If You have questions
				  about how I am paid, please ask Me.
Depending on the annuity You buy, I will or may be paid cash
				  compensation as follows:
Commission, which is usually paid by the insurer or other
				  sources. If other sources, they come from:
				  _______________________________.
Fees (such as a fixed amount, an hourly rate, or a percentage
				  of Your payment), which are usually paid directly by the Consumer.
Other:
				  ____________________________________________________________________________.
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
				  insurer or other sources.
By signing below, You acknowledge that You have read and
				  understand the information provided to You in this document.
__________________________________________
Consumer Signature
______________________
Date
__________________________________________
Insurance Producer Signature
______________________
Date