1 NO DATE: June 27, 2011 TO: FROM: SUBJECT: All Producers Licensed in New Jersey James P. Payne, Compliance Officer Suitability in Annuity Transactions The purpose of this Compliance Bulletin is to inform you of the new annuity suitability requirements adopted by New Jersey and the resulting procedural changes that you must follow when selling any National Western annuity product to consumers of all ages. A copy of the regulation is attached. Please take the time to read this bulletin and the accompanying regulation carefully and to familiarize yourself with all of the requirements. New Jersey adopted Subchapter 59 of the New Jersey Administrative Code, Disclosure and Suitability Requirements for Annuities Directly Solicited to Consumers ; in addition to other requirements, the regulation includes standards and procedures for recommendations to consumers that result in transactions involving annuity products so that the insurance needs and financial objectives of consumers at the time of the transactions are appropriately addressed. NEW ANNUITY SUITABILITY QUESTIONNAIRE JULY 1, 2011 COMPLIANCE DATE As a result of the new regulation in New Jersey, National Western has created a new Annuity Suitability Questionnaire that must be used with all annuity applicants in New Jersey. Effective July 1, 2011, National Western is requiring that Form DM-1174 (or any future revisions thereof) be used with all annuity applicants. This form must accompany all annuity applications dated on or after July 1, 2011, and you should keep a copy of the form for your records. National Western will not issue an annuity unless it has received a properly completed, signed Annuity Suitability Questionnaire. A copy of Form DM-1174 is attached to this bulletin and can be ordered from the Company or downloaded from BEACON. Again, please read the attached regulation carefully and familiarize yourself with the new Annuity Suitability Questionnaire, Form DM-1174, as there are substantial differences from the previous version in New Jersey. For example, please note the following: You are required to obtain more extensive, detailed information from the consumer under the New Jersey regulation such as liquidity needs, risk tolerance, and financial time horizon, in addition to other information that is now required under New Jersey law to determine the suitability of a recommendation. National Western will no longer allow a consumer to opt out of completing the new Annuity Suitability Questionnaire. This form is required for every application in New Jersey and must be completed in its entirety. In the case of an exchange or replacement of an annuity, the new questionnaire requires that (over) SH-1006.Rev.5.06
2 you obtain information regarding surrender charges, any loss of benefits, and previous exchange/replacement activity. National Western must now have procedures to review each of its insurance producer s recommendations prior to the issuance of an annuity that are designed to ensure that there is a reasonable basis to determine that a recommendation is suitable. National Western created its Annuity Suitability Questionnaire, and requires its use in all annuity sales, in order to assist our insurance producers in obtaining information from the consumer that would enable them to make suitable recommendations for the purchase or exchange of an annuity. It is your responsibility to make suitable recommendations based on the facts disclosed by the consumer. Again, please remember that Form DM-1174 (or any future revisions thereof) must be completed in its entirety (including the explanation section of the Agent Certification), all questions answered, and properly initialed and signed where indicated on the form. In addition, New Jersey also requires that the consumer sign a form acknowledging receipt of required notices stated in Subchapter 59. Along with the new Annuity Suitability Questionnaire, you must submit form DM-1198-NJ, Suitability Questionnaire Supplement for New Jersey Consumers. This form must be signed and dated by the consumer, and failure to submit this form to the Company will prohibit policy issuance. A copy of form DM-1198-NJ is attached to this bulletin. NEW INSURANCE PRODUCER TRAINING REQUIREMENTS The new regulation in New Jersey requires that insurers establish supervision procedures that include insurance producer training and monitoring. As a result of this requirement, National Western requires that insurance producers who sell to New Jersey residents must complete two training components: (1) A one-time, four hour general annuity training course approved by the Department and provided by a Department-approved education provider; and (2) Product-Specific Training for National Western annuity products. National Western is a member of the National Association for Fixed Annuities (NAFA), and as a NAFA member, we were able to partner with them to assist you in complying with both the one-time, fourcredit general annuity training and National Western s Product-Specific Training. At any time beginning July 1, 2011 or after, please login to National Western s producer-friendly website, BEACON, and click on the NAFA banner on the right side of your screen to access both the Product-Specific Training and CE course. Once on their website, please click the box entitled Click Here to Select Required Annuity Product Specific Training, select National Western Life as your Carrier, click Continue, and then scroll down and click the box to select National Western Product Specific Training for Annuities. If you only need to take the Product-Specific Training, simply click Add Selected Course to Cart and proceed to finish. To add the CE course as well, click Select Annuity Suitability and CE Training and then click on New Jersey. Select your license type (Life, Annuity, and Health Insurance CE) and then scroll down and click the box to select New Jersey s NAIC Suitability in Annuity Transactions CE course. Once you have made your selections, click Check Out and follow the screen prompts to continue to your training program(s). More specific information as to each program is provided below. NWL Product-Specific Training August 1, 2011 Compliance Date As part of National Western s producer training requirements, an insurance producer may not solicit the sale of any annuity product unless he or she has adequate knowledge of the product to recommend the
3 annuity. In order to ensure that its producers are complying with this requirement, National Western has designed a Product-Specific Annuity Training program to provide product-specific training on its respective annuity products. This program will be available through BEACON beginning July 1, This product-specific training program is a 1.5-hour course that is based on our consumer disclosure brochures and is designed to provide you with knowledge of the types of annuity products offered by National Western as well as the specific features each product provides. To access this course beginning on July 1, 2011, please follow the instructions provided above. Please remember that National Western will not be able to accept any annuity business from you if you have not completed the Product-Specific Training prior to soliciting the sale of an annuity on or after August 1, General Annuity Training CE Course To Be Determined Compliance Date NAFA s continuing education partner, SuccessCE, offers New Jersey s NAIC Suitability in Annuity Transactions CE course, which has been approved by the New Jersey Department of Banking and Insurance and meets this training requirement. To access this course, please follow the instructions provided above. At the end of this course, SuccessCE will notify National Western that you have completed your one-time, four-hour general annuity training course so that National Western can verify that you have completed the required training. If you have already completed this training with another authorized provider, you may , fax, or mail your Certificate of Completion to National Western via the following methods: Fax: (512) Mail: National Western Life Insurance Company Attn: Robin Genz Licensing Supervisor 850 East Anderson Lane Austin, Texas National Western will only accept Certificates of Completion for courses that are approved by the New Jersey Department of Banking and Insurance for this training requirement. Please note that once a compliance date is determined, National Western will not be able to accept any annuity business from you if you have not completed this four-hour general annuity training requirement prior to soliciting the sale of an annuity on or after that date. If you have any problems using our website and/or accessing the training programs, our Marketing Department is ready to assist you. Please direct any questions you may have concerning this Compliance Bulletin to the Marketing Department ( ). JPP/gbm This Compliance Bulletin supersedes Compliance Bulletins 32-04, 02-05, and
5 11: Purpose and scope New Jersey Administrative Code Chapter 4 Actuarial Services Subchapter 59 DISCLOSURE AND SUITABILITY REQUIREMENTS FOR ANNUITIES DIRECTLY SOLICITED TO CONSUMERS (a) The purpose of this subchapter is to set forth the information to be acquired to determine the suitability of an annuity for a consumer and to prescribe disclosure requirements to be utilized in connection with the sale, solicitation or negotiation of annuities directly to consumers, as required by N.J.S.A. 17B:25-34 et seq. This subchapter also implements N.J.S.A. 17B:25-38c(1) by establishing minimum requirements for the system of supervision to be utilized by insurers and producers to ensure compliance with the suitability requirements prescribed by N.J.S.A. 17B:25-38b. (b) This subchapter shall apply to any annuity, both immediate and deferred, directly solicited to a consumer, except as specifically excluded pursuant to N.J.S.A. 17B:25-37a and 17B:25-38a. 11: Definitions Words and terms as defined in the Act at N.J.S.A. 17B:25-35, when used in this subchapter, shall have the meanings as defined in the Act, unless the context clearly indicates otherwise or as further defined by this subchapter. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Act" means N.J.S.A. 17B:25-34 et seq. "Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance. "Department" means the New Jersey Department of Banking and Insurance. "NAIC" means the National Association of Insurance Commissioners. 11: Buyer's guide (a) Pursuant to N.J.S.A. 17B:25-37d, an insurance producer, agent, representative or member of a fraternal benefit society not required to be licensed as an insurance producer pursuant to N.J.S.A. 17:44B-32, or an insurer shall provide a consumer who applies for an annuity a copy of a buyer's guide regarding the sale of annuities. 1. Pursuant to N.J.S.A. 17B:25-37d(1), the buyer's guide shall be provided no later than five business days after receipt of the application. 2. Pursuant to N.J.S.A. 17B:25-37d(2), if the direct response solicitation occurs via the Internet, the requirement in (a)1 above shall be satisfied by: i. Making the buyer's guide available, in printable form, to consumers on the issuing insurer's Internet website, and providing notice to the consumer of its availability; and ii. Allowing consumers to request, through the issuing insurer's Internet website, a mailed copy of the buyer's guide, provided that the insurer provides the documents to the consumer no later than five business days after receipt of the application. 3. If the buyer's guide is not provided in accordance with (a)1 or 2 above, as applicable, the consumer shall have a period of not less than 15 days after receipt of any annuity purchased, or longer if provided by the terms of the annuity, to cancel the annuity and receive from the insurer a prompt refund of any account value of the annuity, including any contract fees or other charges, by mailing or otherwise surrendering the annuity together with a written request for cancellation. This cancellation period shall run concurrently with the cancellation period provided by N.J.S.A. 17B: (b) For purposes of complying with N.J.S.A. 17B:25-37b, such a person or entity shall utilize the Buyer's Guide to Fixed Deferred Annuities, or however otherwise designated, approved by the NAIC and in use at the time the buyer's guide is required to be provided, modified to reflect the 10-day cancellation period for consumers set forth at N.J.S.A. 17B:25-39 and the 15-day cancellation period set forth in N.J.S.A. 17B:25-37d(3) and (a)3 above. The buyer's guide approved for use shall be posted on the Department's website at: 11: Disclosure statement (a) Pursuant to N.J.S.A. 17B:25-37d, an insurance producer, agent, representative or member of a fraternal benefit society not required to be licensed as an insurance producer pursuant to N.J.S.A. 17:44B-32, or an insurer shall provide to a consumer who applies for an annuity a copy of the annuity contract disclosure statement. (b) The annuity contract disclosure statement required for distribution, pursuant to (a) above shall, at a minimum, contain the information and be in the form set forth in N.J.S.A. 17B:25-37c and in the Appendix to this subchapter, incorporated herein by reference.
6 (c) Persons or entities required to utilize the disclosure statement may include such additional information as they deem appropriate, provided such additional information is not inconsistent with any law of this State or administrative rule of the Department or any information required to be disclosed as set forth in the Appendix. (d) The disclosure statement form to be used in connection with an annuity shall be filed with the Department as part of the filing of the annuity form pursuant to N.J.A.C. 11:4-40. For contract forms previously approved, the insurer shall file a copy of a disclosure statement that complies with this section that is to be utilized with such form no later than December 3, Failure to timely file a disclosure statement that complies with this section for use with a previously approved annuity form shall result in such previously filed and approved form being deemed withdrawn. (e) Pursuant to N.J.S.A. 17B:25-37d(1), the disclosure statement shall be provided to the consumer no later than five business days after receipt of the application. (f) Pursuant to N.J.S.A. 17B:25-37d(2), if a direct response solicitation occurs via the Internet, the requirements of this section shall be satisfied by: 1. Making the disclosure statement available, in printable form, to consumers on the issuing insurer's Internet website, and providing notice to the consumer of its availability; and 2. Allowing consumers to request, through the issuing insurer's Internet website, a mailed copy of the disclosure statement, provided that the insurer provides the document to the consumer no later than five business days after receipt of the application. (g) If the disclosure statement is not provided in accordance with (e) or (f) above, as applicable, the consumer shall have a period of not less than 15 days after receipt of any annuity purchased, or longer if provided by the terms of the annuity, to cancel the annuity and receive from the insurer a prompt refund of any account value of the annuity, including any contract fees or other charges, by mailing or otherwise surrendering the annuity together with a written request for cancellation. This cancellation period shall run concurrently with the cancellation period provided by N.J.S.A. 17B: : Suitability standards (a) Pursuant to N.J.S.A. 17B:25-38b(1), an insurance producer, or an agent, representative or member of a fraternal benefit society not required to be licensed as an insurance producer pursuant to N.J.S.A. 17:44B-32, or an insurer, if no producer or non-licensed society agent, representative or member is involved, shall not negotiate or sell an annuity to a consumer unless such person or entity has reasonable grounds for believing that the annuity is suitable for the consumer, on the basis of facts disclosed by the consumer as to the consumer's investments, other insurance products, financial situation and objectives. For purposes of complying with N.J.S.A. 17B:25-38b, the insurance producer, agent, representative or member of a fraternal benefit society not required to be [page=1348] licensed as an insurance producer pursuant to N.J.S.A. 17:44B-32, or the insurer shall, prior to selling an annuity negotiated and/or solicited to a consumer, make reasonable efforts to obtain and record the information required by N.J.S.A. 17B:25-38b(2). (b) For purposes of complying with (a) above, the information required pursuant to N.J.S.A. 17B:25-38b(2)(d) for assessing the suitability of the annuity for a consumer shall be recorded on a form that includes, but need not be limited to, the following information: 1. Age; 2. Annual income; 3. Financial status, including the financial resources used for the funding of the annuity; 4. Financial experience and investment objectives; 5. Intended use of the annuity; 6. Financial time horizon; 7. Existing assets, including investment and life insurance holdings; 8. Liquidity needs; 9. Risk tolerance; and 10. Tax status. (c) Pursuant to N.J.S.A. 17B:25-38b(2)(e), the consumer shall sign a form acknowledging receipt of notice that the solicitation, negotiation and sale of the annuity and its suitability are subject to the regulatory oversight of the Department and of information on how to contact the Department's consumer assistance services. This signed acknowledgement may be a supplement to the suitability form, both of which shall be retained by the insurance producer, non-licensed society agent, representative or member or the insurer who is selling the annuity product to the consumer. (d) If the consumer refuses to provide the relevant information to determine the suitability of the product solicited, such refusal shall be so noted on the suitability form and the form shall then be signed by the consumer or noted as set forth in (e) below prior to the sale of the product. (e) If the consumer refuses to sign the form, such refusal shall be noted thereon by the insurance producer, non-licensed society agent, representative or member or by the insurer. (f) Copies of the signed or notated suitability and acknowledgement forms shall be provided to the consumer upon the request of the consumer.
7 11: Insurer supervision procedures (a) Insurers shall establish and maintain a system of supervision, or contract with a third party to establish and maintain such a system in accordance with N.J.S.A. 17B:25-38c(1), (2) and (3). Any insurance producer or non-licensed society agent, representative or member authorized to act on behalf of the insurer shall adopt the insurer's system of supervision for its own employees and contracted persons who negotiate and sell annuities, or establish and maintain a system to ensure compliance with the consumer suitability requirements set forth in N.J.S.A. 17B:25-38b. The system of supervision shall include: a written set of procedures concerning the negotiation and sale of annuities; a system establishing responsibility for retention of copies of all suitability forms and acknowledgements of receipt of notices by the consumer; and a process for periodic reviews to detect and prevent violations of N.J.S.A. 17B:25-38b. The periodic reviews may consist of such items as the insurer deems necessary, including, but not limited to: 1. Producer training and monitoring; 2. Post-sale sampling systems to identify and monitor trends for unsuitable sales; 3. Analyzing recent annuity applications to identify potentially unsuitable transactions and, based on such results, making additional inquiries and/or taking corrective action; and 4. Analyzing data related to past annuity transactions, including data that identifies trends indicative of potentially unsuitable transactions, such as age, complaints against producer, number of lapses, withdrawals, surrenders, and replacements. Based on such results, insurers shall make additional inquiries and/or take corrective action. 11: Penalties Failure to comply with this subchapter may result in the imposition of penalties as authorized by law, including penalties as authorized pursuant to N.J.S.A. 17B:25-42.
9 ANNUITY SUITABILITY QUESTIONNAIRE FOR ALL APPLICANTS (Please attach additional sheets as necessary) This questionnaire is designed to elicit information about your financial needs and investment objectives so that your agent can determine which product, if any, is suitable for you. Completion of this entire suitability questionnaire is mandatory. The Company uses this form to help monitor the suitability of annuity sales for the benefit of the customer. Joint Owners: In the instance of joint ownership, the Company assumes that all responses are the same for both individuals if the relationship is spousal. If not spousal, separate questionnaires must be completed by each joint owner. Trusts as Owners: See page 5 for instructions on completing this questionnaire for trust-owned annuities. Name of Owner/Applicant Age Date of Birth Name of Joint Owner/Applicant (if applicable) Age Date of Birth Product Name Withdrawal Charge Period Premium Amount FINANCIAL SITUATION AND NEEDS 1. Annual income: $0-$24,999 $25,000-$49,999 $50,000-$99,999 $100,000-$249,999 $250, ,999 $500,000-$999,999 $1,000,000 or higher 2. Sources of income (please enter the percentage of your income attributed to each of the categories below, if applicable): % Salary % Investments % Retirement Plan/Pension Plan % Social Security % Other: 3. Federal Tax Bracket: 10% 15% 25% 28% 33% 35% or higher 4. Approximate Net Worth ( Net Worth means your total assets (including the premium for this annuity, but excluding primary residence or personal property, such as jewelry, furnishings, and vehicles) less your total debts (excluding mortgages on primary residence)): $0-$24,999 $25,000-$49,999 $50,000-$99,999 $100,000-$249,999 $250,000-$499,999 $500,000-$999,999 $1,000,000 or higher 5. What are the financial resources used for the funding of this annuity? (please select all that apply) Annuity* Life Insurance* Certificates of Deposit Savings/checking Account Reverse Mortgage/Home Equity Loan Other investments* *Please Note: If the source of funds is from an annuity contract, life policy, or investment account, please submit your most recent account statement from that policy/contract along with your NWL application. DM-1174.Rev.6.11 Page 1 of 5
10 INTENDED USE OF THIS ANNUITY 6. What are your financial objective(s) in purchasing this annuity? (please select all that apply) Growth for Future Tax Deferral Save for Emergencies General Savings Retirement Income Estate Planning Immediate Income Safety of Principal Other 7. How do you anticipate taking distributions from this annuity? (please select all that apply) Annuitization Single lump sum 10% Penalty-Free Withdrawals Systematic Interest Withdrawals Partial surrenders Loans Leave to beneficiary RMDs Lifetime Withdrawal Payments through Withdrawal Benefit Rider 8. How will contract values, if any, be paid at death? (select one) Payments to beneficiary over a period of five or more years Payment to beneficiary in a single lump sum LIQUIDITY NEEDS AND FINANCIAL TIME HORIZON 9. What is your Liquid Net Worth after the purchase of this annuity? ( Liquid Net Worth means the value of all of your liquid assets, which are assets that could readily convert to cash without imposition of fees or penalties.) $0-$24,999 $25,000-$49,999 $50,000-$99,999 $100,000-$249,999 $250,000-$499,999 $500,000-$999,999 $1,000,000 or higher 10. Do you have sufficient available cash, liquid assets, or other sources of income for living expenses, health care, and emergencies after the purchase of this annuity? Yes No 11. Do you anticipate any significant changes in your household s income, living expenses, or liquid assets during the surrender charge period of the annuity being purchased? Yes No (For example, do you expect a reduction in income caused by retirement or pension changes or by an increase in expenses such as housing, medical, nursing home, assisted living, or travel expenses?) If Yes, please explain: 12. How long do you plan to keep this annuity (i.e., what is your financial time horizon)? (select one) 1-3 Years 4-6 Years 7-9 Years Years Years 16+ Years 13. When do you anticipate taking your first distribution from this annuity? (select one) 1-3 Years 4-6 Years 7-9 Years Years Years 16+ Years FINANCIAL EXPERIENCE 14. Rate your investment knowledge (select one): Limited Average Extensive 15. Rate your risk tolerance (select one): Conservative Moderate Aggressive 16. What other financial products do you own or have you previously owned? (please select all that apply) None Certificates of Deposit Fixed annuities Variable annuities Stocks/bonds/mutual funds Other (please list) _ 17. What is the total amount of your existing assets, including investment and life insurance holdings? $0-$24,999 $25,000-$49,999 $50,000-$99,999 $100,000-$249,999 $250,000-$499,999 $500,000-$999,999 $1,000,000 or higher DM-1174.Rev.6.11 Page 2 of 5
11 EXCHANGE OR REPLACEMENT 18. Is this an exchange or replacement of an annuity or life contract? Yes No If yes, please proceed. If no, please skip to question 19. Type of product being exchanged/replaced (e.g., fixed, fixed indexed, variable annuity) Company Name (e.g., ABC company) Product Name (if applicable) Purchase Date Surrender Value (account value less surrender charge of the product being exchanged/replaced) Surrender Charge (total dollar amount) Example: Fixed Annuity ABC Company Indexer $23,000 $ a) As a result of this transaction, will you lose any existing benefits, experience any tax consequences, or be subject to increased fees or charges for riders or other product enhancements in proceeding with this exchange/replacement? Yes No If yes, please explain: b) Please explain how you will benefit from this annuity s enhancements and improvements compared to the contract you are exchanging/replacing: c) Have you had another annuity exchange or replacement (excluding this one)? Yes within the last 36 months Yes more than 36 months ago No If yes, please explain: ADDITIONAL INFORMATION 19. Do you (or the trust beneficiary/grantor/settlor if a trust is the owner) currently reside in a nursing home or assisted living facility or plan to enter a nursing home or assisted living facility in the next 6 months? Yes No If yes, please explain: 20. Do you understand and accept that you could possibly lose some of your principal if you surrender your policy early during the withdrawal charge period (if your cash surrender value is less than your premium)? Yes No 21. Do you understand and accept that your interest credits will fluctuate depending on the product you are purchasing and, if applicable, the strategy allocation you have selected? Yes No 22. What other information, if any, do you consider material in deciding to purchase this annuity? Please explain: DM-1174.Rev.6.11 Page 3 of 5
12 NOTE: If this form is not completed, signed, and dated, we cannot consider your application. AGENT CERTIFICATION Explain why you have reasonable grounds for believing that the annuity that you recommended is suitable for the owner/applicant, including how he/she will benefit from the purchase of this annuity: _ By signing below, I certify that I have reasonable grounds for believing that my recommendation is suitable on the basis of facts disclosed by the owner/applicant as to financial situation and needs, investments, and other insurance products, and I realize that National Western may issue this annuity in reliance on my recommendation. Agent Signature Agent Address ( to be used for communication regarding suitability) _ Date _ Annuity Agent Number OWNER/APPLICANT CERTIFICATION By initialing beside each statement and signing below, I certify to the following: I have reviewed the Consumer Information Summary and Disclosure brochure that pertains to this annuity with my agent, and I have been reasonably informed of the various features of this annuity, including but not limited to the withdrawal charge period, withdrawal charges, charges for riders, and limitations on interest returns, before deciding to purchase this annuity. I have discussed my current financial and insurance products with my agent before deciding to purchase this annuity. I understand that if I am exchanging or replacing an existing annuity, I may incur surrender charges/fees and that I may not be able to reinstate this replaced contract; however, I believe this transaction to be in my best interest. I understand that if I take money out of this product in excess of the free withdrawal amount provided in the contract during the withdrawal charge period, I will incur a withdrawal charge. I understand that my agent will receive compensation/commission as a result of this transaction. I have reviewed this Annuity Suitability Questionnaire, and I understand its contents. I understand that National Western is relying on the information that I have provided on this questionnaire, and I certify that it is complete and accurate to the best of my knowledge. I have undergone a thorough discussion with my agent regarding the suitability of this annuity, and I certify that it is suitable for my circumstances. Owner/Applicant/Trustee Signature Joint Owner/Applicant/Co-Trustee Signature (if applicable) _ Date _ Date DM-1174.Rev.6.11 Page 4 of 5
13 Instructions for Trusts as Owners In instances in which a trust will be the owner of an annuity, the Company has specific requirements regarding what information must be captured on the Annuity Suitability Questionnaire. Please use the charts below to determine how the questionnaire(s) must be completed and what information needs to be included. In some instances more than one questionnaire is required. In addition, please note the following: For multiple trustees who must act together, the Annuity Suitability Questionnaire must be signed by all trustees. Be sure to complete and submit the Trust Information Form (DM-1094). Revocable Trusts If: Then: The Grantor/Settlor and Trustee are the SAME The grantor/settlor of the Trust must complete the Suitability Questionnaire as to his/her own personal information If there are multiple non-spousal grantors/settlors, a separate Suitability Questionnaire must be completed for each grantor/settlor The trustee(s) must complete the entire Suitability Questionnaire with the Trust s information (net worth, goals, objectives, etc.) including the following modifications: The Grantor/Settlor and Trustee are DIFFERENT For Name of Owner/Applicant, enter the name of the trust; For Age, enter N/A ; For Date of Birth, enter the date on which the trust was established; and For Owner/Applicant/Trustee Signature, the trustee must sign as trustee (e.g., Jane Doe, TTEE) Do NOT include the trustee s personal information -AND IN ADDITION- The grantor/settlor of the Trust must complete a separate Annuity Suitability Questionnaire as to his/her own personal information Irrevocable or Non-Grantor/Settlor Trusts The trustee(s) must complete the entire Suitability Questionnaire with the Trust s information (net worth, goals, objectives, etc.) including the following modifications: For Name of Owner/Applicant, enter the name of the trust; For Age, enter N/A ; For Date of Birth, enter the date on which the trust was established; and For Owner/Applicant/Trustee Signature, the trustee must sign as trustee (e.g., Jane Doe, TTEE) Do NOT include the trustee s personal information DM-1174.Rev.6.11 Page 5 of 5
15 SUITABILITY QUESTIONNAIRE SUPPLEMENT FOR NEW JERSEY CONSUMERS NOTICE TO CONSUMERS: New Jersey requires that its consumers sign a form acknowledging receipt of the information stated below. Please read the following statement and sign where indicated to acknowledge receipt of the required notice. I, the consumer, acknowledge that I have received notice that the solicitation, negotiation, and sale of this annuity and its suitability are subject to the regulatory oversight of the New Jersey Department of Banking and Insurance, and that the contact information for the Department s consumer assistance services is as follows: New Jersey Division of Insurance 1 Consumer Inquiry and Response Center (CIRC) P.O. Box 471, Trenton, NJ Consumer Inquiries and Complaints Phone: or FAX: Signature of Owner/Applicant _ Date INSTRUCTIONS FOR PRODUCERS: This form must be submitted to the Company along with the Annuity Suitability Questionnaire, form DM-1174 (or any future revisions thereof). Failure to submit this form signed by the consumer will prohibit the issuance of the annuity policy. If you have any questions, please contact National Western s Marketing Department ( ). 1 The contact information provided above is as stated on the New Jersey Department of Banking and Insurance website as of June DM-1198-NJ