Section 3120.APPENDIX B   Consumer Refusal to Provide Information

Do Not Sign Unless You Have Read and Understand the Information in this Form

Why are you being given this form?  You’re buying a financial product – an annuity.

To recommend a product that effectively meets your needs, objectives, and situation, the insurance producer, broker, or company needs information about you, your financial situation, insurance needs, and financial objectives.

If you sign this form, it means you have not given the insurance producer, broker, or company some or all the information needed to decide if the annuity effectively meets your needs, objectives, and situation. You may lose protections under the Illinois Insurance Code if you sign this form or provide inaccurate information.

Statement of Purchaser:

          I REFUSE to provide this information at this time.

          I have chosen to provide LIMITED information at this time.

Customer Signature

Date

(Source:  Added at 47 Ill. Reg. 2312, effective February 3, 2023)