Annuity Customer Identification and Suitability Confirmation Worksheet

Transcription

1 Annuity Customer Identification and Suitability Confirmation Worksheet Thank you for your interest in purchasing an annuity offered by Guggenheim Life and Annuity Company, doing business in California as Guggenheim Life and Annuity Insurance Company (Guggenheim Life). Completion of this worksheet is an essential part of the application process. It helps your agent assess your insurance needs and financial objectives and also aids in ensuring compliance with applicable anti-money laundering and sanctions laws. Non-Natural Owners: For a non-natural owner, such as a trust, the information on the front of this form should be relevant to the entity. For Section 8 below, the Customer Identification information should be provided by the person(s) authorized to act on behalf of the entity. If you elect not to provide the requested information, please be advised that Guggenheim Life will not be able to issue the annuity contract for which you are applying. 1. Owner Information OWNER(S) INFORMATION Proposed Owner Name: Joint Owner Name, if any: Place of Birth (City, State, and Country): Place of Birth (City, State, and Country): U.S. Citizen: Yes No U.S. Citizen: Yes No Age: Age: Occupation: Occupation: 2. Product Information PRODUCT APPLIED FOR Multi Year Guaranteed Annuity Single Premium Immediate Annuity Fixed Indexed Annuity Product Name: Initial Premium: $ Surrender Charge Duration: Other Deferred Annuity SUITABILITY 06/2017 NEWBUSINESS@GUGGENHEIMINSURANCE.COM PHONE FACSIMILE Page 1 of 8

2 3. Financial Information and Objectives HOUSEHOLD FINANCIAL INFORMATION (Please include pre-purchase values. If no assets in any listed category, please mark with "0" or "") Annual Household Income (total income from all sources): Annual Household Expenses: Source(s) of Income: Liquid Assets 1. Cash: 2. Mutual Funds (except Class B funds subject to deferred sales charges): 3. Checking/Savings/Money Market: 4. Annuities not subject to surrender penalties: 5. CDs: 6. Life insurance cash value not subject to surrender penalties: 7. IRAs/Qualified Plans (if over 59 ½ and no surrender penalties): 8. Other (personal property such as collectibles and gold are considered non-liquid assets): 9. Stocks/Bonds: Total Liquid Assets (add boxes ): Non-Liquid Assets 10. Value of Home: 11. Gold, collectibles, or other valuable personal property: 12. Other Real Estate: 13. Annuities subject to surrender penalties: 14. IRAs/Qualified Funds (if under 59 ½): 15. Life insurance cash value subject to surrender penalties: 16. Class B Mutual Funds (if subject to deferred sales charges): 17. Other: Total Non-Liquid Assets (add boxes ): Total Assets (Liquid plus Non-Liquid Assets): Total Net Worth (Total Assets minus Total Debt): 3A. What is your risk tolerance? Conservative (Cautious Preservation of principal with guaranteed returns) Moderate (Comfortable exposing some assets to volatility and variation in returns) Aggressive (Attempt to achieve maximum returns - Comfortable taking on additional risk, including risk to principal) SUITABILITY 06/2017 NEWBUSINESS@GUGGENHEIMINSURANCE.COM PHONE FACSIMILE Page 2 of 8

3 3B. Do you anticipate a significant increase in living expenses or a significant reduction in income or liquid assets during the term of this annuity? Yes No If yes, please explain: 3C. What is your combined state and federal tax bracket: 0% - 10% 11%-20% 21%-30% 31%-40% 41%-50% Other: 3D. What is the source of premium for this annuity: Annuity Life Insurance CD IRA 401K Other Retirement (specify) Savings/Checking Other Investments Reverse Mortgage Other: 3E. Is the source of premium from Qualified Funds 1? Yes No 3F. Are there any surrender charges, penalties or settlement fees of any kind associated with the source of funds? Yes (Amount $ ) No 3G. Do you have sufficient liquid assets available for monthly living expenses and emergencies, other than the money you plan to use to purchase this annuity? (Examples: Checking, savings, money market, short term CDs, bonds, etc.) Yes No 3H. Do you have a Reverse Mortgage? Yes No If yes, please explain: 3I. Do you now own, or have you previously owned, any of the following financial products? Check all that apply. CDs yrs Stocks/Bonds/Mutual Funds yrs Life Insurance yrs Fixed Annuities yrs Fixed Indexed Annuities yrs Variable Annuities yrs None (If you now own a life insurance or annuity contract, please complete the IMPORTANT NOTICE REGARDING REPLACEMENT OF LIFE INSURANCE OR ANNUITY, if required by your state). 3J. Were your current investments and insurance products discussed with your agent prior to your decision to purchase this annuity? Yes No 3K. Do you understand and accept that you could possibly lose some of your principal if you surrender your annuity before the end of the surrender charge period? Yes No Not applicable 3L. Why are you purchasing this product? Check all that apply: Income Tax Deferral Lifetime Income Payout Potential Growth Provide Guarantees Pass Assets on to Beneficiaries Preservation of Capital Flexibility Other: 1 Qualified Funds refers to funds which have special tax treatment due to their tax-advantaged, pre-tax, or tax-deferred status (typically by being in or withdrawn from an IRA, 401(k), 403(b) or other retirement plan). SUITABILITY 06/2017 NEWBUSINESS@GUGGENHEIMINSURANCE.COM PHONE FACSIMILE Page 3 of 8

4 3M. Explain how purchasing this annuity will result in a net tangible benefit to you: 4. Accessing Your Money 4A. How do you anticipate taking money from this annuity? Check all that apply: Free Withdrawal Systematic Withdrawal Immediate Income Income Rider Required Minimum Distributions Free Lump Sum Annuitize in the Future I do not anticipate taking any distribution Other: 4B. How long do you plan to take money from this annuity? Not applicable 4C. When do you anticipate taking your first distribution? (choose one) Less than 1 year Between 1-5 years Between 5-10 years 10+ years None anticipated 5. Replacement Information 5A. Is the product applied for replacing or intended to replace one or more existing life insurance or annuity contracts? Yes. (Agent, please complete the Replacement Comparison Table Section) No 5B. Have you replaced any other life insurance or annuity contracts in the past 60 months? Yes No If yes, please provide an explanation for each replacement transaction, including reason for replacement, whether a full or partial surrender was made, and the amount of all surrender charges. 5C. Is the agent assisting you with this transaction the same agent who replaced other life insurance or annuity contracts? Yes No 5D. If the proposed annuity will replace an existing life insurance or annuity contract, resulting in the payment of a surrender penalty, please explain how the replacement will produce a substantial financial benefit over the life of the new annuity: 5E. Is the agent assisting you with this annuity purchase the same agent on the product being replaced? Yes No Not applicable 6. Other Required Information 6A. Are you or your spouse currently in a nursing home or do you plan to enter a nursing home in the next 6 months? Yes No 6B. Have you been diagnosed with a terminal condition or advised by a physician that you have 24 months or less to live? Yes No SUITABILITY 06/2017 NEWBUSINESS@GUGGENHEIMINSURANCE.COM PHONE FACSIMILE Page 4 of 8

5 6C. Do you intend to apply for means-tested government benefits, including, but not limited to, Medi-Cal or the veteran's aid and attendance benefit? (Required for California residents and applications signed in California.) Yes No Not applicable If yes, please explain: 7. Immediate Annuity Acknowledgement For Completion with Immediate Annuities Only Immediate Annuity Acknowledgement: The Life Only or Joint Life settlement option was selected for this immediate annuity contract. Yes No If No, skip to Section 8. If Yes, please read and initial the following: Life Only and Joint Life Disclaimer Statement - The Life Only and Joint Life settlement options will cause payments to be made only during the life of the Annuitant or Joint Annuitant(s). After the last Annuitant's death, no further payments will be made. No payments will be made to the Annuitant's or Joint Annuitant s estate, beneficiaries or any other person. By initialing, I acknowledge that I fully understand the selected payout option and agree to its terms: Annuitant Initials Joint Annuitant Initials 8. Customer Identification OWNER S VERIFICATION (TYPE OF GOVERNMENT-ISSUED PHOTO ID) Drivers License State of Issue Number Expiration Date Passport Country of Issue Number Expiration Date Other State/Country of Issue Number Expiration Date An unexpired government-issued photo ID is not available. If not, provide detailed explanation why an ID is not available. JOINT OWNER S VERIFICATION (TYPE OF GOVERNMENT-ISSUED PHOTO ID) Drivers License State of Issue Number Expiration Date Passport Country of Issue Number Expiration Date Other State/Country of Issue Number Expiration Date An unexpired government-issued photo ID is not available. If not, provide detailed explanation why an ID is not available. SUITABILITY 06/2017 NEWBUSINESS@GUGGENHEIMINSURANCE.COM PHONE FACSIMILE Page 5 of 8

6 9. Prior Related Sales and Agent s Confirmation To be completed by the Agent. 9A. Have you sold this owner any other existing (active) policies or contracts? Yes No 9B. If yes, please provide the following information: Type and Amount of Coverage Issuing Company Issue Date 10. Replacement Comparison Table and Confirmation Section To be completed by the Agent. Completion of this Replacement Comparison Table and Confirmation is an essential part of the application process. This section is required for all replacements where the source of funds are in whole or in part from a life insurance or annuity contract. If you elect not to provide the requested information, please be advised that Guggenheim Life will not be able to issue the annuity contract for which you are applying. Check here if this is not a replacement. If this box is checked, completion of Question 10A, Replacement Comparison Table is not required. SUITABILITY 06/2017 NEWBUSINESS@GUGGENHEIMINSURANCE.COM PHONE FACSIMILE Page 6 of 8

7 10A. Replacement Comparison Table. Please complete for each life insurance and annuity contract being replaced. Attach additional pages as needed. Check here if additional pages are attached. Guggenheim Life and Annuity Product Being Applied For Contract Being Replaced 1 Contract Being Replaced 2 (if applicable) Company Guggenheim Life and Annuity Company Contract Number Contract Type Fixed Fixed Indexed Surrender Type Full Partial Full Partial Multi Year Guaranteed Annuity Product Information Single Premium Immediate Annuity Other Deferred Annuity Qualified Contract Issue Date Premiums Paid Yes No Yes No Yes No $ $ $ Source of Premium Interest Rate Detail Surrender Charge Detail (Years Remaining and Amount) Current Account Value Current Cash Surrender Value Current Death Benefit $ $ $ $ $ $ Applicable Fees Benefits, Riders, Features or Enhancements (Including free withdrawal provisions and bonus features) SUITABILITY 06/2017 NEWBUSINESS@GUGGENHEIMINSURANCE.COM PHONE FACSIMILE Page 7 of 8

8 Confirmation Section Owner s Confirmation By signing below, I acknowledge that the information I provided on this form, regarding my financial circumstances, investment objectives, risk tolerance, identification information and any other information requested by my agent is complete and accurate to the best of my knowledge. I further acknowledge that neither Guggenheim Life nor its representatives offer legal or tax advice and that I have been advised to consult my own personal attorney or tax advisor on any legal or tax matters. I acknowledge that I have been informed of various features of the annuity such as the potential surrender period and surrender charges, any applicable market value adjustments, potential tax penalties upon sale, exchange, surrender or annuitization, potential charges and features of riders. I believe that the annuity for which I am applying is suitable according to my insurance needs and financial objectives. Was your decision to purchase this annuity based on your agent s recommendation? Yes No Owner s Signature Date Joint Owner s Signature Date Agent s Confirmation By signing below, I acknowledge the following: a) I have made a reasonable effort to obtain, and have obtained, information from the Owner(s) concerning the Owner(s) financial circumstances, investment objectives, risk tolerance and other information relevant to my recommendation. b) It is my belief that based on the information the Owner(s) provided and based on all the circumstances known to me at the time the recommendation was made, the annuity being applied for is suitable for the Owner(s). c) My recommendation to purchase the annuity applied for adheres to any standard of care required by applicable law, including in the case the source of premium is from Qualified Funds (as indicated in question 3E above) the Department of Labor s Fiduciary Rule (the Rule ), in which case I have determined that the annuity being applied for is in the best interest of the Owner(s) and that my recommendation for the purchase of such annuity satisfies the requirements of an applicable exemption under the Rule. I further acknowledge that Guggenheim Life is not, where applicable, serving as a Financial Institution (as defined within the Rule). I have verified the identity of the Owner(s) and believe the information each Owner provided to me regarding his or her identity is true and accurate. Was the Owner s decision to purchase this annuity based on your recommendation? Yes No Agent s Signature Date Note: Doing business as Guggenheim Life and Annuity Insurance Company in California SUITABILITY 06/2017 NEWBUSINESS@GUGGENHEIMINSURANCE.COM PHONE FACSIMILE Page 8 of 8