Transaction Date: 05/12/2017
Name of Customer: John Smith
Name of Agent: Jane Doe
Name of Agency or Broker Dealer: Agency, LLC
Name of Product: Marquis® SP Fixed Indexed Annuity
Name of Insurance Company: The Lafayette Life Insurance Company
This Disclosure Statement ("Disclosure") is provided to you in connection with your IRA purchase, purchase of an annuity or life insurance product using a distribution from certain retirement plans, any other transaction involving IRAs or distributions from retirement plans, or your purchase of a product to fund a retirement benefit in your employer sponsored retirement plan. This Disclosure contains important information that I am required to describe to you pursuant to requirements imposed by the U.S. Department of Labor. For purposes of this Disclosure Statement, “I”, “me”, or “my” means the person or persons recommending this transaction; “you,” or “your” means you, the individual(s) signing this Disclosure Statement; and “product” means the annuity or insurance policy that is being recommended to you.
Please read this Disclosure carefully and retain a copy in your records.
1. No Affiliations. I am not an affiliate of the insurance company listed above whose product I am recommending you purchase, hold, or make a transaction in, nor is my ability to make this recommendation limited by an agreement with the Insurance Company.
2. Compensation from Insurance Company. All direct or indirect compensation payable to me by the insurance company in connection with the sale of the product is described below.
3. Fees and Charges. The fees, charges, discounts, penalties or adjustments that may be imposed under the product are described below.
Minimum Index Participation Rate: 10% Minimum Index Interest Rate Cap: 1%
GLWB Rider Charge: Maximum Rider Fee or Individual and Spousal Rider: 1.50% of Benefit Base annually. Annual benefit for Spousal Rider is 90% of Individual benefit. Withdrawals taken before guaranteed payments are available, or for amounts greater than guaranteed amount, may reduce annual lifetime payments
Maximum charge for duplicate annual statement: $25
Withdrawal Charges: '7-Year: 9%, 8.5%, 8%, 7%, 6%, 5%, 4%, 0% 10-Year: 9%,
8.5%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1%, 0%
Compensation paid to Agent for sale of this product (shown as % of contribution / premium):
Producer Number: Writing Agent 00000
Selling Agreement: LLIC/Marquis SP 10/2500-IGA9/01
Age Bands / First Year / Thereafter18-75 / X.X% / X.X%
76+ / X.X% / X.X%
Other compensation that may be paid to Agent in connection with the sale of this product:
See attached, if applicable.
Material Conflicts of Interest. Below are "material conflicts of interest" relevant to the services I am providing you. A "material conflict of interest" exists when I have a
financial interest that a reasonable person would conclude could affect the exercise of my best judgment as a fiduciary in rendering advice to you.
(Instructions: Either list your material conflicts of interest in the space provided or attach separate material conflicts of interest disclosure.)
By signing below, you hereby acknowledge the receipt of this Disclosure Statement and approve the sale of the product to you in connection with your IRA purchase or purchase funded by a distribution from certain retirement plans. You further acknowledge that this Disclosure Statement will cover additional recommendations with respect to the product that occur within one year from the date hereof.
RETIREMENT INVESTOR(S):
By:
Printed Name:
Date:
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