APPENDIX B

[Effective 1/1/2022)

CONSUMER REFUSAL TO PROVIDE INFORMATION

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, broker, 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, broker, 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 Alabama Insurance Code 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

Author: Commissioner of Insurance

Statutory Authority: Code of Ala. 1975, §§27-2-17; 27-12-1, et seq.

History: New Rule: June 10, 2021; effective January 1, 2022. Filed with LRS June 10, 2021. Rule is not subject to the Alabama Administrative Procedure Act.