Disclosure Form For Military Sales printable pdf download

Disclosure Form

for Military Sales

American General Life Insurance Company, Houston TX

American General Life and Accident Insurance Company, Nashville, TN

The United States Life Insurance Company in the City of New York, New York, NY

Subsidiaries of American International Group, Inc.

This disclosure is to inform you of your rights and options when purchasing annuities or life insurance, and to ensure that the solicitation

had been conducted appropriately and in compliance of the state and federal laws concerning sales to military service members.

The Federal Government offers members of the Armed Forces a subsidized group life insurance under the Servicemembers’ Group Life

Insurance program (SGLI) under United States Code subchapter III of chapter 19 of title 38.

The life insurance or annuity product being sold to you as part of this disclosure is not offered or provided by the Federal Government,

and the Federal Government has not sanctioned, recommended, or encouraged the sale of this product. The insurance agent and the

insurer of the product being sold to you are not affiliated with the Armed Services or with the Federal Government as part of this sale.

No person has received any referral fee or incentive compensation in connection with the sale or offer of this life insurance product,

unless they are a licensed agent.

Additional information that may be helpful to you can be located in the brochure that was given to you entitled "Life Insurance

Information for Military Personnel", and on the National Association of Insurance Commissioners (NAIC) web site

Section A: Please check the correct answer for each question:

1. Were you given a brochure called “Life Insurance Information for Military Personnel?

Yes

2. If you have a SGLI, did the agent perform a needs assessment that took into account all other military survival

benefits, savings, investments and insurance?

Yes

3. Were you given an illustration or similar disclosure that explains the type of life insurance, the death benefit

applied for, and the anticipated first year’s cost for the product?

Yes

4. Was the “Free Look” period explained to you?

Yes

5. Did the agent explain how to cancel the proposed insurance policy?

Yes

Section B: Please check the correct answer for each question:

6. Did your SGLI or other government funded benefit fund or partially fund the life insurance or annuity product

being sold to you?

Yes

7. Were you told to pay the premiums from funds from an institution or account that you do not have a banking

relationship where you receive statements or can make withdrawals or deposits to?

Yes

8. Did the agent ask for your “My Pay” PIN, account # or have you fill out a government allotment form?

Yes

Section C: To be asked only if the solicitation occurred on a military installation. Please check the correct answer for each question :

9. If the solicitation occurred on a military base or installation, were you given the military solicitation disclosure

form DD FORM 2885 to give to your commanding officer?

Yes

10. If the solicitation occurred on a military base or installation, were all of the answers to the questions on the

DD FORM 2885 answered “NO”?

Yes

I acknowledge that the questions above were answered honestly to the best of my knowledge.

Proposed Insured Signature ______________________________________________________ Date: __________________

I acknowledge that I have read the “Military Sales Practices” bulletin prior to this solicitation and have to the best of my ability

adhered to all of its requirements. I also acknowledge that any solicitation to a service member of the armed forces adheres to

all state, federal and military regulations and that all of the information provided in this disclosure is accurate. I also understand

that if anything was not disclosed properly that the policy/contract can be voided from its inception by the service member or

their dependents.

Agent Signature ________________________________________________________________ Date: __________________

Agent Name (print) ______________________________________________________________

AGLC103030 Rev0309

Disclosure Form For Military Sales

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