Rules & Regulations of the State of Tennessee
Title 0780 - Commerce and Insurance
Subtitle 0780-01 - Insurance Division
Chapter 0780-01-86 - Suitability in Annuity Transactions
Appendix C - 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 Insurance Code of Tennessee.

________________________________________________

Customer Signature

________________________________________________

Date

________________________________________________

Agent/Producer Signature

________________________________________________

Date