Section 3120.APPENDIX C   Consumer Decision to Purchase an Annuity Not Based on a Recommendation

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 insurance producer, broker 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 insurance producer, broker, or company did not recommend that I buy it. If I buy it without a recommendation, I understand I may lose protections under the Illinois Insurance Code.

Customer Signature

Date

Insurance Producer Signature

Date

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