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DEPARTMENT OF REVENUE AND REGULATION

DIVISION OF INSURANCE

SAMPLE ACKNOWLEDGMENT

Chapter 20:06:38

APPENDIX B

SEE: ยง 20:06:38:13

 

 

 

 

 

 

 

 

          Source: 24 SDR 33, effective September 22, 1997.


SAMPLE ACKNOWLEDGMENT

I certify that I displayed a computer screen illustration for ______________________ that complies with state requirements and for which no hard copy was furnished. The illustration was based on the following personal and policy information:

1.       Gender                                                             Male _____                    Female _____

2.       Age                                                                       _______________________________

3.       Underwriting or rating class                               _______________________________

4.       Type of policy                                                  _______________________________

5.       Type of rider                                                    _______________________________

6.       Initial death benefit                                     _______________________________

7.       Dividend option election                                    _______________________________

          (or application of non-

          guaranteed elements, if

          applicable)

8.       Guaranteed interest rate(s)                         _______________________________

9.       Nonguaranteed interest rate(s)                   _______________________________

                                                                                       _______________________________

                                                                                       AGENT

                                                                                       DATE:_________________________

I acknowledge that I viewed a computer screen illustration based on the information as stated above.  No hard copy of the illustration was furnished.  I understand that an illustration conforming to the policy as issued will be provided to me no later than at the time the policy is delivered.

                                                                                       _______________________________

                                                                                       APPLICANT

                                                                                       DATE:_________________________

An illustration conforming to the requirements of the model must be prepared and personally delivered by the agent on or before delivery of the policy.



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