W. Va. Code R. agency 114, tit. 114, ser. 114-11B, app A
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 West Virginia: _______________________________________________
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 Deposits
Whose Annuities Can I Sell to You?
I am authorized to sell:
[] Annuities from Only One (1) Insurer | [] Annuities from Two or 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. 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:
__________________________________________________________________________________________.
[] 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
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Agent (Producer) Signature
_____________________________________________
Date
W. Va. Code R. agency 114, tit. 114, ser. 114-11B, app A