West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-11B - Suitability In Annuity Transactions › Appendix A - Insurance Agent (producer) Disclosure for Annuities

Current through Register Vol. XLI, No. 28, July 12, 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 West Virginia:
				  _______________________________________________
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. 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:
__________________________________________________________________________________________.
[] 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