W. Va. Code R. agency 114, tit. 114, ser. 114-11B, app B
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 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 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 the Insurance Code of West Virginia and applicable rules 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
W. Va. Code R. agency 114, tit. 114, ser. 114-11B, app B