Sample Permitted Activities Disclosure & Acknowledgement Form

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SAMPLE PERMITTED ACTIVITIES DISCLOSURE & ACKNOWLEDGEMENT FORM
As a licensed annuity professional, I have a number of responsibilities to the individuals and families I serve. My
responsibilities are defined and limited by the professional license(s) I hold. Your understanding of what I can
and cannot do for you is very important. I have an obligation to have reasonable grounds for believing that any
recommendation to purchase or exchange an annuity is suitable for you.
Role of Insurance Agent
1.
I have been informed that _______________________ is a licensed insurance agent and is authorized to sell
fixed life insurance products, including the sale of fixed annuities and fixed indexed annuities. I have been
informed that he or she is an insurance agent, and is not licensed to sell securities or provide investment
advice and advisory services.
2. Suitability
I have been informed that ___________________________has an obligation to have reasonable grounds for
believing that any recommendation to purchase or exchange an annuity is suitable based upon the facts that I
have provided including risk tolerance, financial situation, and stated financial goals and objectives.
3. Product Features
I have been informed of various features of the annuity, such as the potential surrender period and surrender
charge, potential tax penalty if the consumer sells, exchanges, surrenders or annuitizes the annuity, mortality
and expense fees, investment advisory fees, potential charges for and features of riders, limitations on interest
returns, insurance and investment components and market risk.
Investment Advice Described
4.
I understand that ___________________ (insurance agent) is authorized to discuss my financial situation,
needs, and objectives in order to provide advice as part of my overall financial plan and in order to determine
that the recommendation to purchase this annuity is suitable for me. I have been informed that this
discussion may include the financial resources generally available for the funding of the annuity, including my
existing assets, and that this may include discussing the stock market and other investment types in general
terms, including market risks and recent or historic economic events and activities. I acknowledge that
_____________________did not offer any investment advice or recommendation regarding the liquidation
or identification of any securities that might be used to fund the purchase of this annuity. The decision of
which resources to use to fund an annuity is solely my own.
Disclosures
5.
I acknowledge and believe that my agent has not given me investment advice in this transaction and service.
If I require investment, legal, or tax advice, I will seek the services of an attorney, tax adviser, investment
advisor representative or other appropriately-licensed professional.
By signing below, I acknowledge that I have read and fully understand this information, and that I have
received a duplicate copy of this Disclosure and Acknowledgment.
__________________________________________________
_______________________________
Owner’s Signature
Date
__________________________________________________
_______________________________
Joint Owner’s Signature (if applicable)
Date
This sample disclosure and acknowledgement form is an example of a form that an annuity salesperson may use. It should be discussed with an
attorney and appointed insurance company and amended as appropriate so that it fits the specific circumstances and goals of the annuity
salesperson, as well as all regulatory and/or insurance company requirements. The information contained in this sample form is provided for
informational purposes only and is not intended to provide legal advice to any individual or entity.
Copyright 2013. All rights reserved.
Distribution or reproduction of any or all of this material is strictly prohibited without express written permission by NAFA.
2013_0822_RES_PermittedActDiscl
SAMPLE PERMITTED ACTIVITIES DISCLOSURE & ACKNOWLEDGEMENT FORM
As a licensed annuity professional, I have a number of responsibilities to the individuals and families I serve. My
responsibilities are defined and limited by the professional license(s) I hold. Your understanding of what I can
and cannot do for you is very important. I have an obligation to have reasonable grounds for believing that any
recommendation to purchase or exchange an annuity is suitable for you.
Role of Insurance Agent
1.
I have been informed that _______________________ is a licensed insurance agent and is authorized to sell
fixed life insurance products, including the sale of fixed annuities and fixed indexed annuities. I have been
informed that he or she is an insurance agent, and is not licensed to sell securities or provide investment
advice and advisory services.
2. Suitability
I have been informed that ___________________________has an obligation to have reasonable grounds for
believing that any recommendation to purchase or exchange an annuity is suitable based upon the facts that I
have provided including risk tolerance, financial situation, and stated financial goals and objectives.
3. Product Features
I have been informed of various features of the annuity, such as the potential surrender period and surrender
charge, potential tax penalty if the consumer sells, exchanges, surrenders or annuitizes the annuity, mortality
and expense fees, investment advisory fees, potential charges for and features of riders, limitations on interest
returns, insurance and investment components and market risk.
Investment Advice Described
4.
I understand that ___________________ (insurance agent) is authorized to discuss my financial situation,
needs, and objectives in order to provide advice as part of my overall financial plan and in order to determine
that the recommendation to purchase this annuity is suitable for me. I have been informed that this
discussion may include the financial resources generally available for the funding of the annuity, including my
existing assets, and that this may include discussing the stock market and other investment types in general
terms, including market risks and recent or historic economic events and activities. I acknowledge that
_____________________did not offer any investment advice or recommendation regarding the liquidation
or identification of any securities that might be used to fund the purchase of this annuity. The decision of
which resources to use to fund an annuity is solely my own.
Disclosures
5.
I acknowledge and believe that my agent has not given me investment advice in this transaction and service.
If I require investment, legal, or tax advice, I will seek the services of an attorney, tax adviser, investment
advisor representative or other appropriately-licensed professional.
By signing below, I acknowledge that I have read and fully understand this information, and that I have
received a duplicate copy of this Disclosure and Acknowledgment.
__________________________________________________
_______________________________
Owner’s Signature
Date
__________________________________________________
_______________________________
Joint Owner’s Signature (if applicable)
Date
This sample disclosure and acknowledgement form is an example of a form that an annuity salesperson may use. It should be discussed with an
attorney and appointed insurance company and amended as appropriate so that it fits the specific circumstances and goals of the annuity
salesperson, as well as all regulatory and/or insurance company requirements. The information contained in this sample form is provided for
informational purposes only and is not intended to provide legal advice to any individual or entity.
Copyright 2013. All rights reserved.
Distribution or reproduction of any or all of this material is strictly prohibited without express written permission by NAFA.
2013_0822_RES_PermittedActDiscl

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