p0287 Annexus Athene Annotated Suitability Generic
How to fill out a Customer Identification and Suitability Confirmation Worksheet Thank you for your interest in Athene’s Fixed Annuity Product. Please complete this worksheet as part of the application process. The worksheet helps your agent assess your insurance needs and financial objectives. It also ensures compliance with the USA Patriot Act. If additional space is needed please attach another sheet or provide a cover letter of explanation.
Please Note: If applying as a joint owner and your relationship is not spousal, separate worksheets must be completed by each joint owner. For an entity owner (i.e. trust or non-person), information on pages 1 & 2 of the worksheet must be relevant to the entity. The Identification Verification on page 3 should be provided by the person(s) authorized to act on behalf of the entity. Everything must be answered. N/A is not an acceptable answer.
Financial Status 1. Owner Name - First, middle initial and Last Name must be listed 2. Joint Owner Name - First, middle initial and Last Name must be listed. Leave blank if not applicable. 3. For annuity applied for, indicate a. Premium $ - Must match application b. Surrender Charge Period - 8, 10 or 12 years. Must match product applying for. Example: BCA12 should be 12 years
4. Monthly Household Gross Income - Number must represent the entire household even if applying for individual policy
5. Monthly Household Living Expenses - Number must represent the entire household even if applying for individual policy
6. Monthly Household Disposable Income - To achieve this number, take the answer from question #4 and subtract the answer from question #5. Number must represent the entire household even if applying for individual policy.
7. Source of Income - Current wages should only be checked if occupation is listed on page 3. Retired is an unacceptable answer unless “Spouse’s Income” is noted in the “Other” section.
8. Federal Income Tax Bracket - Rate at which Owner’s earnings are taxed
GEN
For Agent Use Only - Confidential
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9. Approximate Household Net Worth - Net worth cannot be less than the total of the premium (question #3a) plus the liquid assets (question #10)
10. Liquid Assets after annuity purchase - Amount of liquid assets Applicant owns, not including this annuity purchase
11. Are your existing liquid assets being used to purchase this annuity? * Does not include primary residence, personal possessions, cars, etc. ** Not all investment vehicles are included. If not facing a penalty for transfer/rollover, liquid assets are probably being used.
a. If YES, what percentage will be used? - If answered yes to question #11, use the following equation to determine the percentage of liquid assets being used. Premium + liquid assets = (total)
Premium/total = percentage
Example: 20,000 + 80,000 = 100,000
20,000/100,000 = 0.2 (20%)
12. Do you have sufficient liquid assets available for emergencies, not including funds from this annuity? - Yes or No 13. If Question 13 is answered yes, explanation must be given. Explanation should advise the increase/decrease in income and any changes in expenses.
14. If all are 0 years, please select none. a. Please answer yes or no. b. If answered yes to 14a, please answer yes or no.
GEN
For Agent Use Only - Confidential
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Financial Objectives 15. Did you discuss your current financial and insurance products with your agent before deciding to purchase this annuity? - Yes or No 16.
a. Answer must be yes. b. Answer must be yes.
17. Please check all that apply. Please Note: If Income Rider is selected then at least one of the below boxes should be checked. Income Now Potential growth followed by Income Lifetime Income Payout
18. Do you anticipate taking any money or income from this annuity?
If Income Rider is wanted, then question 18 must be checked yes. If no money or income is going to be taken from this annuity, then this question must be checked no.
19. Please select the type(s) and the time frame in which you anticipate utilizing the option:
If question 18 is Yes, a time frame for utilizing the Income Rider and any other method for taking income must be checked. If question 18 is No, this question should be left blank.
20. How long do you plan to keep this annuity? - Must be answered with one selection 21. Please explain if answer is Yes. 22. Must be answered. Do not leave blank. N/A is not an acceptable answer. None is an acceptable answer.
GEN
For Agent Use Only - Confidential
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Source of Funds 23. What is the source of funds for this annuity? - Please check all that apply. a. Answer yes or no b. If question 23a is Yes, please provide the company name or type for each source of premium and list:
The dollar amount and percentage of any surrender charge, penalty, bonus recapture charge, other costs or fees associated with the source of funds. DO NOT REDUCE AMOUNT/PERCENTAGE BY ANY BONUS ON THIS ANNUITY OR ANY OFFSET SUCH AS A POSITIVE MARKET VALUE ADJUSTMENT (MVA). If there is a Replacement and a penalty percentage is listed, it must match the penalty percentage listed in Question 11 for the ‘Replaced Contract’ on the Product Comparison Worksheet. The dollar amount listed should equal the value of the penalty percentage from the Accumulated Value noted in Question 8 for the ‘Replaced Contract’ on the Product Comparison Worksheet.
Customer Identification Verification US Citizen - Yes or no must be checked Occupation - List the Owner’s occupation, or Retired Place of Birth - If in U.S., City and State must be listed Type of Government Issued Photo ID - Must check one. If Other, please explain. ID Number - List ID number listed on Photo ID, Example: A123-456-78-910-0 State or Country of Issue - List state or country Photo ID was issued in and the expiration date (MM/DD/YYYY)
GEN
‘Unexpired Government issued photo ID not available’ is acceptable to check but will require additional documents requested by carrier. If in U.S., state must be listed.
For Agent Use Only - Confidential
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Agent’s Confirmation
(A, B, C and D must be completed.)
A. Was the owner’s decision to purchase this annuity based on your recommendation? If question is answered No, an additional letter of explanation is required.
B. Must be answered. C. Must be answered. N/A is not an acceptable answer. ‘None’ is an acceptable answer. D. Must be answered. Agent signature and date are required.
Owner’s Confirmation Was your decision to purchase this annuity based on your agent’s recommendation? If question is answered No, an additional letter of explanation is required.
Client signature and date are required. Joint Owner’s signature and date are required if applicable.
GEN
For Agent Use Only - Confidential
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Please Note: If applying as a joint owner and your relationship is not spousal, separate worksheets must be completed by each joint owner. For an entity owner (i.e. trust or non-person), information on pages 1 & 2 of the worksheet must be relevant to the entity. The Identification Verification on page 3 should be provided by the person(s) authorized to act on behalf of the entity. Everything must be answered. N/A is not an acceptable answer.
Financial Status 1. Owner Name - First, middle initial and Last Name must be listed 2. Joint Owner Name - First, middle initial and Last Name must be listed. Leave blank if not applicable. 3. For annuity applied for, indicate a. Premium $ - Must match application b. Surrender Charge Period - 8, 10 or 12 years. Must match product applying for. Example: BCA12 should be 12 years
4. Monthly Household Gross Income - Number must represent the entire household even if applying for individual policy
5. Monthly Household Living Expenses - Number must represent the entire household even if applying for individual policy
6. Monthly Household Disposable Income - To achieve this number, take the answer from question #4 and subtract the answer from question #5. Number must represent the entire household even if applying for individual policy.
7. Source of Income - Current wages should only be checked if occupation is listed on page 3. Retired is an unacceptable answer unless “Spouse’s Income” is noted in the “Other” section.
8. Federal Income Tax Bracket - Rate at which Owner’s earnings are taxed
GEN
For Agent Use Only - Confidential
1
9. Approximate Household Net Worth - Net worth cannot be less than the total of the premium (question #3a) plus the liquid assets (question #10)
10. Liquid Assets after annuity purchase - Amount of liquid assets Applicant owns, not including this annuity purchase
11. Are your existing liquid assets being used to purchase this annuity? * Does not include primary residence, personal possessions, cars, etc. ** Not all investment vehicles are included. If not facing a penalty for transfer/rollover, liquid assets are probably being used.
a. If YES, what percentage will be used? - If answered yes to question #11, use the following equation to determine the percentage of liquid assets being used. Premium + liquid assets = (total)
Premium/total = percentage
Example: 20,000 + 80,000 = 100,000
20,000/100,000 = 0.2 (20%)
12. Do you have sufficient liquid assets available for emergencies, not including funds from this annuity? - Yes or No 13. If Question 13 is answered yes, explanation must be given. Explanation should advise the increase/decrease in income and any changes in expenses.
14. If all are 0 years, please select none. a. Please answer yes or no. b. If answered yes to 14a, please answer yes or no.
GEN
For Agent Use Only - Confidential
2
Financial Objectives 15. Did you discuss your current financial and insurance products with your agent before deciding to purchase this annuity? - Yes or No 16.
a. Answer must be yes. b. Answer must be yes.
17. Please check all that apply. Please Note: If Income Rider is selected then at least one of the below boxes should be checked. Income Now Potential growth followed by Income Lifetime Income Payout
18. Do you anticipate taking any money or income from this annuity?
If Income Rider is wanted, then question 18 must be checked yes. If no money or income is going to be taken from this annuity, then this question must be checked no.
19. Please select the type(s) and the time frame in which you anticipate utilizing the option:
If question 18 is Yes, a time frame for utilizing the Income Rider and any other method for taking income must be checked. If question 18 is No, this question should be left blank.
20. How long do you plan to keep this annuity? - Must be answered with one selection 21. Please explain if answer is Yes. 22. Must be answered. Do not leave blank. N/A is not an acceptable answer. None is an acceptable answer.
GEN
For Agent Use Only - Confidential
3
Source of Funds 23. What is the source of funds for this annuity? - Please check all that apply. a. Answer yes or no b. If question 23a is Yes, please provide the company name or type for each source of premium and list:
The dollar amount and percentage of any surrender charge, penalty, bonus recapture charge, other costs or fees associated with the source of funds. DO NOT REDUCE AMOUNT/PERCENTAGE BY ANY BONUS ON THIS ANNUITY OR ANY OFFSET SUCH AS A POSITIVE MARKET VALUE ADJUSTMENT (MVA). If there is a Replacement and a penalty percentage is listed, it must match the penalty percentage listed in Question 11 for the ‘Replaced Contract’ on the Product Comparison Worksheet. The dollar amount listed should equal the value of the penalty percentage from the Accumulated Value noted in Question 8 for the ‘Replaced Contract’ on the Product Comparison Worksheet.
Customer Identification Verification US Citizen - Yes or no must be checked Occupation - List the Owner’s occupation, or Retired Place of Birth - If in U.S., City and State must be listed Type of Government Issued Photo ID - Must check one. If Other, please explain. ID Number - List ID number listed on Photo ID, Example: A123-456-78-910-0 State or Country of Issue - List state or country Photo ID was issued in and the expiration date (MM/DD/YYYY)
GEN
‘Unexpired Government issued photo ID not available’ is acceptable to check but will require additional documents requested by carrier. If in U.S., state must be listed.
For Agent Use Only - Confidential
4
Agent’s Confirmation
(A, B, C and D must be completed.)
A. Was the owner’s decision to purchase this annuity based on your recommendation? If question is answered No, an additional letter of explanation is required.
B. Must be answered. C. Must be answered. N/A is not an acceptable answer. ‘None’ is an acceptable answer. D. Must be answered. Agent signature and date are required.
Owner’s Confirmation Was your decision to purchase this annuity based on your agent’s recommendation? If question is answered No, an additional letter of explanation is required.
Client signature and date are required. Joint Owner’s signature and date are required if applicable.
GEN
For Agent Use Only - Confidential
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