Form DFS-H1-1980 "Annuity Suitability Questionnaire" - Florida

Form DFS-H1-1980 or the "Annuity Suitability Questionnaire" is a form issued by the Florida Department of Financial Services.

A PDF of the latest Form DFS-H1-1980 can be downloaded below or found on the Florida Department of Financial Services Forms and Publications website.

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Download Form DFS-H1-1980 "Annuity Suitability Questionnaire" - Florida

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DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services - Bureau of Investigation
ANNUITY SUITABILITY QUESTIONNAIRE
Owner: Last
First
Middle
Female
Date of Birth
/
/
Age
Sex
Entity:
Tax Status
Relationship to Annuitant(s):
Form of Ownership:
Supporting documents (list):
Annual Income:
Source of Income:
Annual Household Income:
Existing Assets
Existing Liquid Net Worth:
Do you currently own any annuities? Please list:
Yes
No
Do you currently own life insurance? Please list:
Yes
No
Does your income cover all your living expenses including medical?
Yes
No
Do you expect changes to your living expenses?
Yes
No
Do you anticipate changes in your out-of-pocket medical expenses?
Yes
No
Is your income sufficient to cover future changes in your living and/or
Yes
No
out-of-pocket medical expenses during the surrender charge period?
Do you have an emergency fund for unexpected expenses?
Yes
No
Why are you purchasing this annuity?
What are your financial objectives for this purchase?
(Check all that apply)
Income
Growth (long term)
Safety of Principal and Income
Safety of Principal and Growth
Pass assets to a beneficiary or beneficiaries at death
Other:
Owner’s Signature
Date Signed
DFS-H1-1980
Rule 69B-162.011, F.A.C.
Effective 10/21/2014
DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services - Bureau of Investigation
ANNUITY SUITABILITY QUESTIONNAIRE
Owner: Last
First
Middle
Female
Date of Birth
/
/
Age
Sex
Entity:
Tax Status
Relationship to Annuitant(s):
Form of Ownership:
Supporting documents (list):
Annual Income:
Source of Income:
Annual Household Income:
Existing Assets
Existing Liquid Net Worth:
Do you currently own any annuities? Please list:
Yes
No
Do you currently own life insurance? Please list:
Yes
No
Does your income cover all your living expenses including medical?
Yes
No
Do you expect changes to your living expenses?
Yes
No
Do you anticipate changes in your out-of-pocket medical expenses?
Yes
No
Is your income sufficient to cover future changes in your living and/or
Yes
No
out-of-pocket medical expenses during the surrender charge period?
Do you have an emergency fund for unexpected expenses?
Yes
No
Why are you purchasing this annuity?
What are your financial objectives for this purchase?
(Check all that apply)
Income
Growth (long term)
Safety of Principal and Income
Safety of Principal and Growth
Pass assets to a beneficiary or beneficiaries at death
Other:
Owner’s Signature
Date Signed
DFS-H1-1980
Rule 69B-162.011, F.A.C.
Effective 10/21/2014
Describe your risk tolerance:
(Check all that apply)
Conservative
Moderately conservative
Moderate
Moderately aggressive
Aggressive
Other:
Comments:
Describe your investment experience by type and length of time:
What is the source of the funds for the purchase of the proposed annuity?
How many years from today will you need access to your funds without a
penalty?
Will the proposed annuity replace any product?
Yes
No
If yes, will you pay a penalty or other charge to obtain these funds?
Yes
No
If yes, the amount of the charge or penalty
$
Additional Information:
Owner’s Signature
Date Signed
DFS-H1-1980
Rule 69B-162.011, F.A.C.
Effective 10/21/2014
Page 2 of 4
Note:
The following three sections to be completed by the agent, insurer, or Managing General Agent
proposing purchase; each section requires a response; no section may be left blank or contain a
response consisting of “None” or “N/A”
.
Advantages of purchasing the proposed annuity:
Disadvantages of purchasing the proposed annuity:
The basis for my recommendation to purchase the proposed annuity or to replace or
exchange your existing annuity (ies):
Agent’s Signature
Date Signed
Note: No questions or response areas are to be left blank when offered to the Owner for signature. If any
information requested is unavailable, not applicable or unknown, the insurance agent or insurer must indicate
that.
ACKNOWLEDGEMENTS AND SIGNATURES
I understand that should I decline to provide the requested information or should I provide inaccurate
information, I am limiting the protection afforded me by the Florida Statutes regarding the suitability of
this purchase.
I
to provide this information at this time.
REFUSE
I have chosen to provide
information at this time.
LIMITED
My annuity purchase
on the recommendation of this
IS NOT BASED
agent or the insurer.
My annuity purchase
on the recommendation of this agent
IS BASED
or the insurer.
APPLICANT:
D
,
O NOT SIGN THIS FORM IF ANY ITEM HAS BEEN LEFT BLANK
BEFORE CAREFULLY REVIEWING THE
,
INFORMATION RECORDED
OR IF ANY OF THE INFORMATION RECORDED IS NOT TRUE AND CORRECT
.
TO THE BEST OF YOUR KNOWLEDGE
T
HE OWNER MAY SUBSTITUTE THEIR INITIALS FOR SIGNATURES ON ALL FORM PAGES WITH THE
,
.
EXCEPTION OF THE SIGNATURES BELOW
WHICH ARE REQUIRED
Owner’s Signature
Date Signed
DFS-H1-1980
Rule 69B-162.011, F.A.C.
Effective 10/21/2014
Page 3 of 4
E
T
XPLANATION OF
ERMS
“Age” is the natural person’s attained age on the day the form is completed.
“Tax Status” is the owner’s Federal Income Tax filing status such as “single” or “married filing jointly”; if “Exempt”, so
state.
“Form of Ownership” is the type of entity, other than a natural person, including a corporation, trust, partnership, limited
liability company, or other business or not-for-profit entity.
“Supporting documents” are the documents that provide a basis for the relationship between the Proposed Annuitant,
and the Owner as it may exist.
“Annual income” is income received during a calendar year, whether earned or unearned.
“Source of annual income” is the income-generating source, such as pension income, dividends, or earned income etc.
“Annual household income” is the combined annual income received by all household members each calendar year.
“Existing Assets” are financial assets including life insurance and annuities.
“Existing Liquid Net Worth” is applicable to those net assets that can readily be converted into their cash equivalent,
without loss of principal after all surrender charges or other deductions have been taken
.“Financial Objectives” are the owner’s stated goals as described to the insurance agent or insurer, if no insurance
agent is involved. These may include but are not limited to the following: (1) Income, (2) Growth (long term capital
appreciation), (3) Safety of Principal and Income, (4) Safety of Principal and Growth, (5) To pass the investment to a
beneficiary or beneficiaries at death.
“Risk Tolerance” means the degree of uncertainty that an investor can reasonably tolerate with regard to a negative
change in his or her investments. Examples of risk tolerance levels may include the following: (1) Conservative (prefer
little or no risk), (2) Moderately conservative (some risk, reduced safety of principal), (3) Moderate (average risk with
potential losses and potentially higher returns), (4) Moderately aggressive (above average risk with potential losses,
risk of principal and potentially higher returns), (5) Aggressive (willing to sustain losses or loss of principal in pursuit of
higher returns).
“Source of the funds” to be used to purchase the proposed annuity means from where the funds will come to purchase
the annuity, and may include but are not limited to; (1) An existing annuity or life insurance contract, (2) Liquid Assets,
including but not limited to, cash in banks, maturing certificates of deposit, and money market accounts, (3) Personal
Loans, (4) Equity Loans, (5) Mortgages, Reverse Mortgages, (6) Death Benefit Proceeds, (7) Funds received upon
retirement from employment, including but not limited to, 401(k) accounts, pensions, and other tax-sheltered funds, (8)
Equities, mutual funds, or bonds, (9) Proceeds from real estate transactions.
Owner’s Signature
Date Signed
DFS-H1-1980
Rule 69B-162.011, F.A.C.
Effective 10/21/2014
Page 4 of 4
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