N.M. Admin. Code tit. 13, ch. 9, pt. 20, app A
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
N.M. Admin. Code tit. 13, ch. 9, pt. 20, app A