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CONSUMER PROFILE and SUITABILITY QUESTIONNAIRE FOR FIXED ANNUITIES
This form is an essential part of the application process. It helps your producer assess your financial situation, insurance needs, financial objectives, and make recommendations appropriate to your situation. All questions must be answered, and the form must be signed by each owner/applicant and the producer. For trust owned annuities, responses will depend on whether the trust is revocable or irrevocable. For revocable trust ownership, responses should be provided based on the grantor’s/settlor’s information. For irrevocable trust ownership, responses should be provided based on the finances of the trust. OWNERS/APPLICANTS: (If the contract will be jointly owned, please provide information for both.) Product Name _______________________________ Purchase Payment $_____________ Plan Type Qualified Non-Qualified **___________________________________________________ _________________________________________________ Owner/Applicant 1 – First Name Last Name
Social Security Number / Tax I.D. Number Age
Owner/Applicant 2 – First Name Last Name
Social Security Number / Tax I.D. Number Age FINANCIAL PROFILE:** (If the contract will be jointly owned, the information may be combined for both.)
1. What is your gross monthly household income? $ ____________________________ a. What are your sources of income? (select all that apply) Wages/Salary Rental Income Investments Pension/Retirement Benefit SSI Other _____________________________________ 2. Describe your monthly income: it is stable - or- it fluctuates 3. What are your monthly household living expenses? $ ____________________________ (Includes: housing, food, transportation, insurance, medical care, and property taxes.) 4. Federal Income Tax Rate: <10% 11 - 20% 21 - 30% 31 - 36% 37%+ 5. What is the total value of your Household Liquid Assets : $___________________ Indicate each liquid asset below: Checking/Savings $_________________ CD’s $____________________ Money Market $_______________________ Stocks/Bonds $_____________________ Mutual Funds $_____________ Pension/401(k) (if over 59 ½) $___________ Fixed Annuities $____________________ Fixed Index Annuities $_______________ Variable Annuities $___________ Life Insurance Cash Value $____________ Other $____________ If Other, provide details: _________________________ (Only include annuities and life insurance out of surrender period.) 6. What is your Household Liquid Net Worth after the annuity purchase? $___________________ (Liquid net worth is the amount that can be easily converted into cash without paying any kind of penalty or surrender charge.) 7. What is the total value of your Household Non-Liquid Assets: $ ____________________________ Indicate each asset below: Real Estate (exclude primary residence) $_______________________ Pension/401(k) (if under 59 ½) $_________________ Fixed Annuities $____________________ Fixed Index Annuities $_______________ Variable Annuities $___________
Life Insurance Cash Value $____________ Other $____________ If Other, provide details: _________________________ (Only include annuities and life insurance in a surrender period.) 8. What is the value of your Household Assets (Total Liquid Assets + Non-Liquid Assets) $_________________________ 9. What is the current value for your Existing Household Debts (excluding primary mortgage) $____________________ 10. What is your Household Net Worth (Total Assets – Existing Debts) $_____________________________ 11. What percentage of your Household Net Worth do all Annuities represent (including proposed purchase)****? ______% (Total annuity holdings ÷ net worth) 12. Is your current income or liquid assets sufficient for living expenses, medical expenses, or any unexpected emergencies? Yes No If No, please explain: __________________________________________________________________________________ 13. After the purchase of this annuity, do you anticipate any material changes to the following? (If Yes, please select the option(s) that will be affected and provide an explanation below.) Yes No Monthly Income Out-of-pocket Medical Expenses Living Expenses Liquid Assets If Yes, please explain: _________________________________________________________________________________ 14. Do you have an emergency fund for unexpected expenses? Yes No If No, please explain: __________________________________________________________________________________ 15. Do you have a reverse mortgage? Yes No 16. Do you reside in a nursing home or assisted living facility? Yes No 17. Do you intend to apply for Medicaid, Medi-Cal, the veterans’ aid and attendance benefit or other means-test government benefits? Yes No (If Yes, you must provide a letter from an attorney certifying that this annuity purchase does not adversely affect your eligibility to participate in the applicable federal or state program. This letter should be submitted along with the application.) **FINANCIAL OBJECTIVES AND EXPERIENCE:
- Reason for Purchase Including Insurance Needs:** (select all that apply) Principal Preservation Growth/Wealth Accumulation Tax Deferral (non-qualified only) Income Retirement/Estate Planning Inheritance/Death Benefit Other **____________________________________
- Which of the following financial products do you own and/or have previously owned and indicate number of years for each?** (select all that apply) Fixed Annuities _____ years Variable Annuities _____ years Life Insurance _____ years Bonds _____ years Stocks _____ years Other ________________________ _____ years CDs _____ years Mutual Funds _____ years 20. Source of funds for this annuity purchase? (select all that apply) (If annuity contracts or life insurance policies are being replaced, the replacement chart for question 2 6 will need to be completed.) Current Income Life Insurance IRA/Retirement Plan Cash/Savings/Checking Annuity Stocks/Bonds/Mutual Funds
Minimum Guaranteed Interest Rate Death Benefit Value Living Benefit Value Interest Crediting Method Type (if applicable) Mortality & Expense Fee, Administrative Fee (Percentage) Living Benefit Rider Fee Death Benefit Rider Fee 28. Is there a surrender charge for liquidating the existing contract? Yes No If Yes, what is the Surrender Charge? (Dollar and/or percentage) __________________________ **29. Please describe what benefit(s) the owner/applicant will achieve by replacing the current contract or policy. If the owner/applicant is giving up a living or death benefit rider please explain why the rider is no longer needed.
ADDITIONAL REMARKS:**
OWNER/APPLICANT’S STATEMENT: I confirm that I provided the information above and that it is true and complete to the best of my knowledge. I discussed my current financial situation, anticipated financial needs and risk tolerance with my producer. The producer discussed with me the surrender charges, if applicable, and other costs relating to this annuity contract. Furthermore, I reviewed the product-specific Disclosure Statement and understand the product features, its interest crediting elements, and if applicable, the indexes upon which the interest calculation will be based. I understand the risks associated with this product include fluctuating interest rates and potentially lower returns. My producer discussed with me the advantages and disadvantages of this annuity contract as well as the basis (bases) of the recommendation. I understand that if I refused to provide all of the requested information or provided inaccurate information, the ability of my producer and Protective Life Insurance Company to determine suitability may be affected. Please check the box next to the statement(s) below that apply. The application will not be accepted if this section is incomplete. I have determined that purchasing this annuity contract supports my insurance needs and will assist me in meeting my financial goals and objectives. (^) I have selected this product despite a contrary recommendation (or absence of a recommendation) from my producer. (If selected, you must complete the Consumer Decision to Purchase an Annuity NOT Based on a Recommendation form.) (^) I REFUSE to provide any or a LIMITED amount of information to the questions above. (If selected, you must complete the Consumer Refusal to Provide Information form.) New Jersey residents ONLY: The sale and suitability of annuities is regulated by the Department of Banking and Insurance and consumers may obtain assistance from the Department by contacting 609- 292 - 7272 or 1- 800 - 446 - 7467, or visiting the Department’s website at www.njdobi.org. Applicant 1: _______________________________________________________________ Date: _____________________ Applicant 2: _______________________________________________________________ Date: _____________________
PRODUCER’S STATEMENT:
I have made a reasonable effort to obtain the following information about the applicant(s): financial resources, net worth and liquidity, tax status, investment objectives, risk tolerance, time horizon, and financial goals and objectives. I have discussed with the applicant the advantages and disadvantages of this product in the context of that information. Sections a. and b. must be completed to confirm the advantages and disadvantages of this purchase. I considered or compared other Protective products available to me. a. Advantages of purchasing the proposed annuity: (select all that apply) Guarantees Immediate Income Lower Risk More Stability Safety of Principal Reduced Fees Guaranteed Lifetime Withdrawal Benefit (GLWB) Rider Retirement Income Other, please explain: __________________________________________________________________________ b. Disadvantages of purchasing the proposed annuity: (select all that apply) Surrender Period/Length Surrender Charges Chance for Less Gain than Current Product Loss of Death Benefit Replacement/Transfer Penalty Other, please explain: __________________________________________________________________________ Please provide the basis (bases) of recommendation for this purchase (required field): ________________________________
Please check the box next to one of the statements below. The application will not be accepted if this section is incomplete. (^) Based on the information the applicant supplied and the applicant’s circumstances of which I am currently aware, I believe the recommended product is suitable, appropriate, and will help achieve the applicant’s insurance needs and financial objectives. The applicant selected this product despite a contrary recommendation (or absence of a recommendation) from me. (If selected, the Consumer Decision to Purchase an Annuity NOT Based on a Recommendation form must be completed.) Producer: ________________________________________________________________ Date: _____________________ Protective Life Insurance Company • PO Box 10648 • Birmingham, AL 35202- 0648 • 800 - 456 - 6330 • Fax 205- 268 - 3151 PROTECTIVE LIFE INSURANCE COMPANY IS NOT LICENSED IN NEW YORK
