DEPARTMENT OF REVENUE AND REGULATION

DIVISION OF INSURANCE

SAMPLE ACKNOWLEDGMENT

Chapter 20:06:38

APPENDIX B

SEE: § 20:06:38:13

SAMPLE ACKNOWLEDGMENT

I certify that I displayed a computer screen illustration for ______________________ that complies with state requirements and for which no hard copy was furnished. The illustration was based on the following personal and policy information:

1. Gender Male _____ Female _____

2. Age _______________________________

3. Underwriting or rating class _______________________________

4. Type of policy _______________________________

5. Type of rider _______________________________

6. Initial death benefit _______________________________

7. Dividend option election _______________________________

(or application of non-

guaranteed elements, if

applicable)

8. Guaranteed interest rate(s) _______________________________

9. Nonguaranteed interest rate(s) _______________________________

_______________________________

AGENT

DATE:_________________________

I acknowledge that I viewed a computer screen illustration based on the information as stated above. No hard copy of the illustration was furnished. I understand that an illustration conforming to the policy as issued will be provided to me no later than at the time the policy is delivered.

_______________________________

APPLICANT

DATE:_________________________

An illustration conforming to the requirements of the model must be prepared and personally delivered by the agent on or before delivery of the policy.

Source: 24 SDR 33, effective September 22, 1997.