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Attached is a template with sample language that outlines the disclosure requirements of Prohibited Transaction Exemption 84-24.

  • If you are a:
  • Registered representative of a Broker Dealer (BD) - please check with your BD back office to understand their requirements
  • Non-registered representative - please check with your Broker General Agency or upline to understand their requirements

A few important notes about this template:

  • It represents Lincoln’s interpretation of the disclosure requirements of PTE 84-24
  • This template disclosure document does not outline other obligations (like impartial conduct standards and reasonable compensation) that the fiduciary may have under PTE 84-24
  • Because Lincoln is not the fiduciary, the obligation to provide disclosures under PTE 84-24 does not rest with Lincoln.
  • In advance of using this template you, as the fiduciary, should review it to ensure you are comfortable that the content satisfies the exemption, as the fiduciary is ultimately responsible for ensuring compliance with the DOL fiduciary rule and its exemptions
  • It is unbranded, as it is meant to be generic and is not specific to Lincoln products.
  • Please note that, when submitting business, Lincoln does not need to receive a copy of this template. All copies of DOL fiduciary rule disclosures should remain with the producer and/or client.

84-24 DISCLOSURE & CONSENT FORM

Disclosures

In order to comply with conditions of Prohibited Transaction Class Exemption 84-24, as amended, these disclosures are being provided by the undersigned (“Agent”) in connection with Agent’s recommendation to , (the“Plan”) to purchase , an insurance contract(the“Contract”) from , the“Carrier”):

1.Agent will receive commissions from the Carrier on the Contract. The commission to be paid by Carrier to Agent in connection with the Plan’s purchase of the Contract is asfollows:

% of the gross annual premium payments for the first year of the Contract;

% of the gross annual premium payments for each of succeeding renewal year (s) of the Contract.

2.Agent□[is]□[isnot]affiliatedwiththeCarrier.Ifaffiliated,thenatureoftheaffiliationis:




3.Agent □[is] □[is not] limited by an agreement with the Carrier to sell only the Carrier’s products. If limited, the detailsare:




4.In addition to a commission, the following amounts may also be imposed under the Contract:

Surrender Charges / Year1%Year2%Year3%Year4%Year5%Year6%
Other Charges
Fees
Discounts
Penalties
Adjustments

DATE:AGENTNAME:

SIGNATURE:


This Disclosure and Consent is effective as of the date on the signature page and is made by the Client, in connection with the purchase of an insurance or annuity contract, with assets of an employee benefit plan described in section 3(3) of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) or a plan described in section 4975(e)(1)(A) of the Internal Revenue Code of 1986, as amended (“IRC”), or any account or annuitydescribedinIRCsection4975(e)(1)(B)through(F)(eachreferredtoasthe“Plan”).

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Consent

The undersigned Client represents and acknowledges that the Client:

  • is a fiduciary of the Plan or is the IRAowner;
  • is independent of theCarrier;
  • is not an insurance agent or broker, pension consultant or insurance company otherwise involved in thetransaction;
  • will not receive, directly or indirectly, any compensation or consideration for the undersigned’s own personal account from any party dealing with the Plan in connection with thetransaction;
  • has received the foregoing disclosures;and
  • approves the purchase of the Contract on behalf of the Plan orIRA.

DATE:CLIENTNAME:

SIGNATURE:

FOR AGENT USE ONLY:

  • This form is for use from June 9, 2017 through December 31, 2017only
  • Retain this form in client file for six (6)years