Section 3120.APPENDIX A   Insurance Producer Disclosure for Annuities

Do Not Sign Unless You Have Read and Understand the Information in this Form

Date:                                                              

INSURANCE PRODUCER INFORMATION (“Me”, “I”, “My”)

First Name:                                                                 Last Name:                                                     

Business\Agency Name:                                             Website:                                                         

Business Mailing Address:                                                                                                                

Business Telephone Number:                                                                                                            

Email Address:                                                                                                                                  

Insurance Producer Number in Illinois:                                                                                            

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 Illinois 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 Index 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 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’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 or a fee. Commissions are generally paid to me by the insurance company while fees are generally paid to me by the consumer. 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:                                                                                .

          Fees (such as a fixed amount, an hourly rate, or a percentage of your payment), which are usually paid directly by the customer.

          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

Insurance Producer Signature

Date

(Source:  Added at 47 Ill. Reg. 2312, effective February 3, 2023)