Form An07091 - Fixed Annuity Suitability And Replacement Form Page 2
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26. AVAIlAblE FunDs
Do you have sufficient cash or other liquid assets for living expenses and any expenses for unexpected emergencies, such as medical
expenses, in excess of the premium you are paying for this fixed annuity?
h Yes h No
If “No”, please explain: _____________________________________________________________________________________
7. tImE HOrIZOn
When do you anticipate needing the money in this annuity?
(This question applies to a deferred annuity and does not apply to a Single Premium
Immediate Annuity (“SPIA”).)
h less than 3 years
h at least 3 years, but less than 5 years h at least 5 years, but less than 7 years
h at least 7 years, but less than 10 years
h 10 years or more
h N/A
(SPIA)
8. DIstrIbutIOns
How do you anticipate taking distributions from this annuity?
(check all boxes that apply) (This question applies to a deferred annuity and
does not apply to a Single Premium Immediate Annuity (“SPIA”).)
h Annuitize
h Partial surrenders
h Lump sum
(including “free partial withdrawals”)
h Required Minimum Distribution
h Systematic withdrawals
h N/A
(SPIA)
9. surrEnDEr cHArGEs
a. I understand that this annuity contract has surrender charges for early withdrawals, surrenders or termination. I intend to keep the
annuity contract at least through the contract’s surrender charge period. I have been provided with and read a product disclosure
statement that discloses the surrender charge period and the surrender charge percentages for this annuity contract.
(These statements apply to a deferred annuity and do not apply to a Single Premium Immediate Annuity (“SPIA”).)
h Yes h No
h N/A
b. I understand that the SmartIncome
Inflation Annuity contract has surrender charges for early unscheduled payments. I have
SM
been provided with and read a product disclosure statement that discloses the surrender charge period and the surrender charge
percentages for this annuity contract.
h Yes h No
h N/A
OWnEr/ApplIcAnt’s stAtEmEnt
I confirm the information given is accurate. My agent has discussed surrender charges and other costs with me and I believe that the annuity
contract is appropriate for my insurance needs and financial objective(s).
________________________________________________________________________
____________________________
Owner/Applicant’s Signature
Date
________________________________________________________________________
____________________________
Joint Owner/Applicant’s Signature
Date
AGEnt’s stAtEmEnt
I recommend the purchase of this annuity contract, which I believe is a suitable recommendation based on information provided by the
Owner/Applicant(s) regarding his/her insurance needs and financial objective(s). I have discussed the advantages and disadvantages of
discontinuing or modifying an existing long-term care policy, life insurance policy or annuity contract
with my client, includ-
(if applicable)
ing the replacement concerns and issues mentioned above. I have determined that the existing coverage or annuity contract
(if applicable)
no longer meets the client’s insurance needs and objectives and that the proposed annuity contract is appropriate in accordance with
the Company’s Fixed Annuity Suitability Position Statement and, if applicable, Appropriateness of Replacements Position Statement. I
have used only Company approved sales material in conjunction with this sale. I have left copies of all sales material with the Owner/
Applicant(s) at the time the Application was submitted.
________________________________________________________________________
____________________________
Agent’s Signature
Date
________________________________________________________________________
Agent’s Printed Name
Page 2 of 2
AN07091
8/08
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