Annuity Suitability Forms

Department of Business Regulation Insurance Division 1511 Pontiac Avenue, Bldg. 69-2 Cranston, Rhode Island 02920 Insurance Bulletin Number 2021-2 Forms for compliance with 230-RICR-20-25-1 The following form is designated for use in compliance with 230-RICR-20-25-1 – Annuity Suitability: APPENDIX A INSURANCE AGENT (PRODUCER) DISCLOSURE FOR ANNUITIES 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 Rhode Island:_________________________________________________ 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 Deposit Whose Annuities Can I Sell to You? Annuities from Only One (1) Insurer Annuities from Two of 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 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 APPENDIX B CONSUMER REFUSAL TO PROVIDE INFORMATION Do Not Sign Unless You Have Read and Understand the Information in this Form Why are You being given this form? You’re buying a financial product – an annuity. To recommend a product that effectively meets Your needs, objectives and situation, the agent, broker, or company needs information about You, Your financial situation, insurance needs and financial objectives. If You sign this form, it means You have not given the agent, broker, or company some or all the information needed to decide if the annuity effectively meets Your needs, objectives and situation. You may lose protections under Rhode Island law if You sign this form or provide inaccurate information. Statement of Purchaser: I REFUSE to provide this information at this time. I have chosen to provide LIMITED information at this time. Customer Signature Date APPENDIX C Consumer Decision to Purchase an Annuity NOT Based on a Recommendation Do Not Sign This Form Unless You Have Read and Understand It. Why are You being given this form? You are buying a financial product – an annuity. To recommend a product that effectively meets your needs, objectives and situation, the agent, broker, or company has the responsibility to learn about You, your financial situation, insurance needs and financial objectives. If You sign this form, it means You know that you’re buying an annuity that was not recommended. Statement of Purchaser: I understand that I am buying an annuity, but the agent, broker or company did not recommend that I buy it. If I buy it without a recommendation, I understand I may lose protections under Rhode Island law. Customer Signature Date Agent (Producer) Signature Date