APPENDIX C

[Effective 1/1/2022)

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 agent, 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 agent, 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 Alabama Insurance Code.

Customer Signature

Date

Agent (Producer) 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.