[This document is provided for informational purposes only and does not constitute legal advice. You are solely responsible for ensuring the accuracy and completeness of all materials as well as the enforceability of all materials under any applicable law. You are advised to consult with a qualified attorney in making any such determination.]
PTE 84-24 Disclosure and Acknowledgement Form for
Individual Retirement Account Life Insurance Purchase
Customer Name: ______(“You” or “Customer”)
Agent Name :______(“Agent”)
Product Name: ______(“Policy”)
Product Type: ______
Issuing Insurance Company: ______
This Disclosure and Acknowledgement Form (“Form”) provides important information you should know and consider before making a purchase of, or payment to, the Policy recommended by Agent with funds from an IRA or other qualified plan. This Form is provided pursuant to applicable law, and in particular, ERISA Prohibited Transaction Exemption 84-24.
BEST INTEREST STANDARD
At the time of the recommendation of the Policy, the Agent believes that their advice is in your “best interest.” This means that the advice reflects the care, skill, prudence and diligence under the circumstances then prevailing that a prudent person acting in a like capacity and familiar with such matters would use in the conduct of an enterprise of a like character with like aims, based on your investment objectives, risk tolerance, financial circumstances, and needs, without regard for the financial or other interests of the Agent.
REASONABLE COMPENSATION
The insurance company issuing thePolicy will pay commissions to the Agent when you make premium payments to your Policy. Commission amounts are determined by the issuing insurance company.If you purchase the Policy, the insurance company will pay the Agent as follows:
____% of amount of gross annual premium paid to the insurance company during the first policy year; and/or
____% of amount of gross annual premiumpaid to the insurance company each succeeding year the Policy is in force after the first year as long as premiums are paid
Additional premiums paid to the insurance company after the first policy year and renewals of the Policycould result in additional commissions, but such commissions will not be more than the first year percentage.
[NOTE TO AGENT: There are also certain situations where the commissions paid by the insurance company may be split between individual agents or between an agent and an agency. In such a case, the agent may decide to disclose the full commission paid by the insurance company or the commission paid to the Agent recommending the Policy.]
CHARGES AND FEES
A full description of the charges and other features of your Policy are provided in the Policy or Policy Summaryprovided you at the time of sale. It is important that you understand the charges that may be imposed under the Policyyou are purchasing. Please ask the Agent if you have any questions.
AGENT AFFILIATION AND LIMITATIONS
Agent is a licensed agent authorized to sell insurance products. Agent may not be licensed to sell securities products. Agent may only sell the products of insurance companies with which agent is appointed. These factors may limit the ability of Agent to recommend certain products to you.
MATERIAL CONFLICTS OF INTEREST
The Agent may have conflicts of interest in connection with the recommendation of the Policy. AMaterial Conflict of Interest exists when the Agent may have a financial interest that a reasonable person would conclude could affect the exercise of his/her best judgment as a fiduciary in rendering advice to you.
The Agent is paid commission by the insurance company that issues the Policy. Commissions are based upon a percentage of gross annual premium you pay. As a result, the Agent is paid more the more insurance you purchase. The Agent may receive different amounts of total compensation for different policies or from different insurance companies.
The Agent may receive or provide services to third parties related to the marketing, training, administration, wholesaling, supervision, issuance, and servicing of the Policy. Such third parties may also receive commissions from the insurance company and may allocate a portion of its commissions to the Agent.
The Agent may receive additional incentives in relation to your purchase of the Policy, including but not limited to gifts, meals, or entertainment of reasonable value, reimbursement for training, marketing, educational efforts, advertising, or travel expenses to conferences or events sponsored by insurance companies or third parties, or participation in bonus programs.
[Additional conflicts of interest______]
Acknowledgment / Approval
I,______, [printed name of Customer] am the owner of an IRA or other qualified plan and the Agent has recommended that I purchase the Policy. I acknowledge that I have received and reviewedthis Form and the Policy or Policy Summaryincluding information concerning compensation and other fees under the Policy. I approve the purchase of the Policy.
Signature of Customer
______Date ______
Signature of Agent
______Date ______
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