W. Va. Code R. agency 114, tit. 114, ser. 114-11B, app C
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 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 or company did not recommend that I buy it. If I buy it without a recommendation, I understand I may lose protections under the Insurance Code of West Virginia and applicable rules.
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Customer Signature
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Date
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Agent (Producer) Signature
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Date
W. Va. Code R. agency 114, tit. 114, ser. 114-11B, app C