S.D. Admin. R. tit. 20, art. 20:06, ch. 20:06:38, app B

Current through Register Vol. 51, page 67, December 16, 2024

Appendix B - Sample Acknowledgment

SAMPLE ACKNOWLEDGMENT

I certify that I displayed a computer screen illustration for ______________________ that complies with state requirements and for which no hard copy was furnished. The illustration was based on the following personal and policy information:

1. Gender Male _____ Female _____

2. Age _______________________________

3. Underwriting or rating class _______________________________

4. Type of policy _______________________________

5. Type of rider _______________________________

6. Initial death benefit _______________________________

7. Dividend option election _______________________________

(or application of non-

guaranteed elements, if

applicable)

8. Guaranteed interest rate(s) _______________________________

9. Nonguaranteed interest rate(s) _______________________________

_______________________________

AGENT

DATE:_________________________

I acknowledge that I viewed a computer screen illustration based on the information as stated above. No hard copy of the illustration was furnished. I understand that an illustration conforming to the policy as issued will be provided to me no later than at the time the policy is delivered.

_______________________________

APPLICANT

DATE:_________________________

An illustration conforming to the requirements of the model must be prepared and personally delivered by the agent on or before delivery of the policy.

S.D. Admin. R. tit. 20, art. 20:06, ch. 20:06:38, app B

24 SDR 33, effective 9/22/1997.