Update by liuhongmei

VIEWS: 5 PAGES: 14

									                        eld e
                      Fi t
                     p da
               U
September 22, 2010
Number: 0276



Reminder of Florida Annuity Suitability Producer
Requirements
In November 2008, Aviva provided guidance to agents regarding agent responsibilities under Florida Senate
Bill 2082. In addition, new Suitability Questionnaire and Disclosure and Comparison of Annuity Contracts forms
were required for annuities sold in Florida after December 25, 2009. Please note that these forms are for
Florida Annuity sales only. In order to assist you in ensuring your new business is processed as efficiently as
possible, Aviva is providing a reminder of existing requirements that Florida law imposes for the sale of annuities.

Under Florida law you have the responsibility to:

       • Ensure that with every annuity sale, a fully-completed Suitability Questionnaire is signed by the
         Applicant/Owner on each page. Incomplete forms will result in a delay in processing the business.

       • Ensure that for all annuity replacements, a Disclosure and Comparison of Annuity Contracts is fully
         completed. Incomplete forms will result in a delay in processing the business.

       • Promptly forward all completed forms to Aviva. Florida law requires that you provide Aviva the
         completed Suitability Questionnaire and Disclosure and Comparison of Annuity Contracts form within 10
         days after the execution of the form. To assist you in meeting the 10-day requirement, the required
         forms can by faxed to Annuity New Business at 866-709-3921. Please be aware that if Aviva receives
         either of these forms more than 10 days from their execution, Florida law requires that you obtain newly
         completed forms, which could result in a delay in processing your business.

       • Provide completed forms to the client. In addition to promptly providing Aviva with the required forms,
         Florida law requires that you provide the client with a copy of the required forms no later than the date
         of contract delivery.

Both of the referenced Florida-specific forms are attached to this announcement and are also available on your
agent portal, Aviva Live. Should you have any questions regarding your responsibilities, please contact Sales
Support at (800) 255-2405, ext 6620.
Date: November 13, 2008
Number: 0315


Overview of Florida Senate Bill 2082
The State of Florida recently passed Senate Bill 2082, effective January
1, 2009, which may impact your business practices and licensure
requirements in Florida. Below is an overview of the new legislation
and the associated penalties for violations.

Producer Responsibilities for Continuing Education and Licensure
• Completion of a minimum of 3 hours of approved life and annuity
   suitability continuing education courses. (These hours may be used
   to satisfy your continuing education requirements in ethics.)

•   Notification to the Florida Department of Insurance in writing
    within 60 days after a change of name, residence address, principal
    business street address, mailing address, contact telephone
    numbers, including business telephone number, or email address.
    Failure to notify the department within the 60 day period shall
    result in a fine of $250 for the first offense and for subsequent
    offenses, a fine of at least $500.

Unfair Methods of Competition
There are new penalties for violations of unfair methods of
competition, which include churning, use of fraudulent signatures,
and unlawful use of designations.

1. Churning/Twisting - Churning or twisting involving fraudulent
conduct will be considered a misdemeanor of the first degree, which is
punishable by a possible term of imprisonment not to exceed 1 year;
and an administrative fine not greater than $5,000 shall be imposed
for each non-willful violation or an administrative fine not greater
than $30,000 shall be imposed for each willful violation.

       Churning - Churning is an unethical and illegal sales practice
       designed solely to generate commission income for an agent.
       Funds from an in-force policy are used to purchase additional
       insurance products with the same insurer, which are not in the
       best interest of the consumer, but results in a new commission
       for the agent.

       Twisting - Knowingly making misleading representations or
       incomplete or fraudulent comparisons or fraudulent material
       omissions of or with respect to any insurance policies or insurers
       for the purpose of inducing, or tending to induce, any person to
       lapse, forfeit, surrender, terminate, retain, pledge, assign,
       borrow on, or convert an insurance policy or to take out a policy
       of insurance in another insurer.
                                                                 continued
                                   Overview of Florida Senate Bill 2082--Page 2
2. Fraudulent Signatures - Willfully submitting fraudulent signatures on an application or
policy related document will be considered a felony of third degree punishable by a term of
imprisonment not exceeding 5 years and an administrative fine.

3. Designations - No sales presentation should use a designation or title in such a way to
falsely imply that a producer has special knowledge or training or that the producer is
certified or qualified to provide specialized services to a senior citizen. A producer may
not use terms such as “financial advisor” in a way that falsely implies that the producer is
licensed or qualified to discuss, sell or recommend financial products other than insurance.
In addition, a producer may not, in any sales presentation or solicitation for insurance,
falsely imply that she is qualified to discuss, recommend or sell securities or other investment
products in addition to insurance products. If the producer holds a Certified Financial
Planner, Chartered Life Underwriter, Chartered Financial Consultant, Life Underwriter
Training Council Fellow, or an appropriate license to sell securities from FINRA, the producer
may inform the customer of those designations or licenses, provided it is not done in a
fraudulent way. We will advise you, should this law change the use of any designations
currently approved for use by Aviva. Please review the previous Compliance Update on the
Use of Professional Designations, October 4, 2007.

Suitability, Replacements and Disclosures
• A Buyer’s Guide will need to be provided to the client at the time of sale.

•   The free look period must be at least 14 days.

•   Reasonable efforts will need to be made to obtain information concerning the suitability
    of the recommendation. The information required will be collected on a form approved
    by the department.

•   You will be required to provide the insurance carrier with a completed copy of the
    suitability form within 10 days of its execution and a copy will need to be left with the
    client no later than the date of delivery of the contract.

•   If the consumer refuses to provide relevant information that is required, before the sale,
    you are to obtain a signed verification from the consumer on a form approved by the
    department that the client refuses to provide the information.

•   Before executing a replacement of an annuity, a comparison of the existing policy and
    the new policy must be completed on a newly approved form.

•   You will be required to provide the insurance carrier with a completed copy of the
    comparison form within 10 days of its execution and a copy will need to be left with the
    client no later than the date of delivery of the contract.

Aviva will make the approved forms available to you as soon as they are available. We will
also advise you of any business and/or process changes that may impact the manner in which
you conduct Florida business with Aviva.

Should you have any questions please contact the Compliance Department.
                     eld e
                   Fi t
                  p da
            U
December 16, 2009
Number: 0222


New Forms Required in Florida
Annuity Suitability Questionnaire and Disclosure and Comparison of Annuity Contracts

As previously communicated, Florida Senate Bill 2082 required the Department of Financial Services to
prescribe a new Suitability Questionnaire and Disclosure and Comparison of Annuity Contracts for
annuity sales. The Department of Financial Services has formally adopted Rule 69B-162.011
providing the form requirements with an effective date of 12/25/09. The new Suitability Questionnaire
will be required with ALL annuity applications in Florida and is available for use immediately. In addition,
a Disclosure and Comparison of Annuity Contracts will be required with all annuity applications that are
replacements. Below are a few things to keep in mind while filling out the Suitability Questionnaire and
the Disclosure and Comparison of Annuity Contracts forms:

       • Answer all questions. Fill in all blanks, including a written explanation, to ensure New Business
          has all of the information needed to process and eliminate the need to return the form for
          additional information. If no answer is needed, enter N/A or Not Applicable. Filling the form
          out completely the first time will result in much faster processing times.
       • The Applicant/Owner is required to Sign and Date EACH page of the form(s).
       • If you need additional space to provide further information, please attach any supplemental
          sheets and have the Applicant/Owner sign & date each page.
       • The Suitability Questionnaire provides an option for the client to decline to provide some or all
          of the information requested on the form (page 5). Please note that it is Aviva’s current
          business practice to only process applications where the suitability form has been entirely
          completed and all questions have been answered on the form. Please be aware if the client
          selects the option to decline to provide some or all of the information requested on the form,
          this will delay processing and may result in the denial of the application.

In addition to the new forms, the State of Florida is taking steps to further protect consumers. Some of
the points addressed by Florida Senate Bill 2082 include changes in Continuing Education and Licensure
as well as Unfair Methods of Competition, which include churning business, submitting fraudulent
signatures and improper use of designations. These measures are being implemented to provide
additional safety measures for consumers and outline fines including possible imprisonment for not
meeting these requirements.

The State of Florida has made use of the new forms effective 12/25/09. All new annuity business
received by the company after 12/23/09 will require a properly completed Suitability Questionnaire and
the Comparison of Annuity Contracts form will also be required if the new business is a replacement.

Both of the forms are attached to this announcement and are available on the Aviva Agent Portal.
If you have any questions, please contact Sales Support at (800) 255-2405, ext. 6620.
We appreciate YOU and YOUR BUSINESS!!
Annuity Suitability Questionnaire
                                                                                          Aviva Life and Annuity Company
                                                                                                         www.avivausa.com

Thank you for your interest in Aviva’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.
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, information on pages 1 - 3 of the worksheet must be relevant to the entity.
The Identification Verification on page 4 should be provided by the person(s) authorized to act on behalf of the entity.
1. PROPOSED ANNUITANT’S PERSONAL INFORMATION
Name: Last _______________________________________________ First ______________________ Middle _____________
Date of Birth _______/_______/_______ Age ________ Sex ______ Tax Status _____________        ______________
                                                                                     __________
Number and Age of Dependents: _____ _____________________________________________________________________
                                     ___

2. JOINT ANNUITANT’S PERSONAL INFORMATION
Name: Last _______________________________________________ First ______________________ Middle _____________
Date of Birth _______/_______/_______ Age _______ Sex ______ Tax Status _____________         ______________
                                                                                    ___________
Number and Age of Dependents: _______________________________________________________________
 3. APPLICANT/OWNER’S PERSONAL INFORMATION (OTHER THAN ANNUITANT/JOINT ANNUITANT)
Owner: Last _______________________________________ First __________________ Middle __________
Date of Birth _______/_______/_______ Age _______ Sex ______
Number and Age of Dependents: _______________________________________________________________
Entity: __________________________________________________________________________________
Tax Status ________________________________ Relationship to Annuitant(s): _________________________
Form of Ownership: ___________________________________________________________       ______________
Supporting documents (list): _____________________________________________________   ______________
 4. JOINT APPLICANT/JOINT OWNER’S PERSONAL INFORMATION (OTHER THAN ANNUITANT/JOINT ANNUITANT)
Owner: Last _______________________________________ First __________________ Middle __________
Date of Birth _______/_______/_______ Age _______ Sex ______
Number and Age of Dependents: _______________________________________________________________
Entity: __________________________________________________________________________________
Tax Status ________________________________ Relationship to Annuitant(s): _________________________
Form of Ownership: ___________________________________________________________       ______________
Supporting documents (list): _____________________________________________________   ______________

___________________________________________________ ____________________________________________________________________________
Applicant/Owner’s Signature                         Date

___________________________________________________ ____________________________________________________________________________
Joint Applicant/Joint Owner’s Signature             Date

DFS-HI-1980 (Effective 10/25/2009)
17363 10/09 FL                               *17363100901*                                   Adopted in Rule 69B-162.011, F.A.C.
                                                                                                                    Page 1 of 6
   Annuity Suitability Questionnaire

                                                     Applicant/       Joint Applicant/
     5.                                                                                       Annuitant        Joint Annuitant
                                                      Owner             Joint Owner
     a. Annual Income:
     b. Source of Income:
     c. Annual Household Income:
     d. Net Worth:
     e. Liquid Assets:
     f. Do you currently own any annuities?        o Yes     o No      o Yes     o No       o Yes     o No      o Yes     o No
     Please list:


     g. Do you currently own life insurance?       o Yes     o No      o Yes     o No       o Yes     o No      o Yes     o No
     Please list:


                                                    Applicant/        Joint Applicant/
     6.                                                                                       Annuitant        Joint Annuitant
                                                     Owner              Joint Owner
     a. Does your income cover all your living
                                                   o Yes     o No      o Yes     o No       o Yes     o No      o Yes     o No
        expenses including medical?
     Explain:

     b. Do you expect changes to your living
                                                   o Yes     o No      o Yes     o No       o Yes     o No      o Yes     o No
        expenses?
     Explain:

     c. Do you anticipate changes in your out
                                                   o Yes     o No      o Yes     o No       o Yes     o No      o Yes     o No
        of pocket medical expenses?
     Explain:

     d. Is your income sufficient to cover
        future changes in your living and/or
                                                   o Yes     o No      o Yes     o No       o Yes     o No      o Yes     o No
        out of pocket medical expenses
        during the surrender charge period?
     If no, please explain:

     e. Do you have an emergency fund for
                                                   o Yes     o No      o Yes     o No       o Yes     o No      o Yes     o No
        unexpected expenses?
     Please explain:

     f. Why are you purchasing this annuity?

    ___________________________________________________ ___________________________________________________________________________
    Applicant/Owner’s Signature                         Date Signed
    ___________________________________________________ ___________________________________________________________________________
    Joint Applicant/Joint Owner’s Signature             Date Signed

DFS-HI-1980 (Effective 10/25/2009)
17363 10/09 FL                                   *17363100902*                                  Adopted in Rule 69B-162.011, F.A.C.
                                                                                                                       Page 2 of 6
Annuity Suitability Questionnaire

7.   What are your investment objectives? (Check all that apply)
	    o Income o Growth (long term) o Safety of Principal and Income
	    o Safety of Principal and Growth o Pass assets to a beneficiary or beneficiaries at death
	    o Other: _____________________________________________________________________________

8. Describe your risk tolerance: (Check all that apply)
	 o Conservative o Moderately conservative o Moderate o Moderately aggressive
	 o Aggressive o Other: ___________________     ________________________________________________
   Comments: _____________________________       _______________________________________________
   _______________________________________________________________________________        ______

9. Describe your investment experience by type and length of time: _____________________________
   ____________________________________________________________________________________
10. How long do you plan to keep the proposed annuity?
    ____________________________________________________________________________________
11. How do you anticipate taking money from this annuity? Check all that apply:
    o Free/Systematic withdrawals o Free/Lump Sum o Income Rider o Required Minimum Distributions
    o Immediate Income o Annuitize in the future o I don’t anticipate taking any distributions
    o Other please explain: _____________________ ___________________________________________     ___

12. When do you first plan to take money from this annuity?
    o Less than 1 year o 1 to 5 years o 6 to 9 years o 10 or more years
    o I don’t anticipate taking any distributions
13. What is the source of the funds for the purchase of the proposed annuity?
                                                                                    _
     ____________________________________________________________________________________
14. Will the proposed annuity replace any product? o Yes o No
    If yes, will you pay a penalty or other charge to obtain these funds? o Yes          o No
    If yes, the amount of the charge or penalty $_______________
15. Is the purchase of this annuity in any way related to the establishment of a trust or based in any
    way on information provided during the establishment of a trust?
    o Yes o No If yes, please explain: ________________________   _________________________________

___________________________________________________ ____________________________________________________________________________
Applicant/Owner’s Signature                         Date Signed

___________________________________________________ ____________________________________________________________________________
Joint Applicant/Joint Owner’s Signature             Date Signed




DFS-HI-1980 (Effective 10/25/2009)
17363 10/09 FL                                 *17363100903*                                 Adopted in Rule 69B-162.011, F.A.C.
                                                                                                                    Page 3 of 6
    Annuity Suitability Questionnaire

   CUSTOMER IDENTIFICATION VERIFICATION
  Owner Verification                                               Joint Owner Verification
  US Citizen: o Yes o No                                           US Citizen: o Yes o No
  Occupation                                                       Occupation
  Place of Birth                                                   Place of Birth

  Type of Government Issued Photo ID                               Type of Government Issued Photo ID
  ID Number                                                        ID Number
  State or Country of Issue          Exp. Date                     State or Country of Issue          Exp. Date
  OR                                                               OR
  o Unexpired Government issued photo ID not available.            o Unexpired Government issued photo ID not available.
  AGENT’S CONFIRMATION
  Note: This section is to be completed by the agent, insurer, or Managing General Agent proposing purchase.
  16. Advantages of purchasing the proposed annuity:




  17. Disadvantages of purchasing the proposed annuity:




  18. The basis for my recommendation to purchase the proposed annuity or to replace or exchange your
      existing annuity(ies):




  19. Was the owner’s decision to purchase this annuity based on your recomendation:                         o Yes o No
  ___________________________________________________ ____________________________________________________________________________
  Agent’s Signature                                   Date Signed

  Note: No questions or response areas are to be left blank when offered to the Annuitant and or
  Applicant/Owner for signature. If any information requested is unavailable, not applicable or unknown,
  the insurance agent or insurer must indicate that.

  ___________________________________________________ ____________________________________________________________________________
  Applicant/Owner’s Signature                         Date Signed

  ___________________________________________________ ____________________________________________________________________________
  Joint Applicant/Joint Owner’s Signature             Date Signed




DFS-HI-1980 (Effective 10/25/2009)
17363 10/09 FL                                    *17363100904*                                 Adopted in Rule 69B-162.011, F.A.C.
                                                                                                                       Page 4 of 6
    Annuity Suitability Questionnaire

   OWNER’S CONFIRMATION, ACKNOWLEGEMENTS AND SIGNATURES
  I understand that should I decline to provide the requested information or should I provide inaccurate information, I am
  limiting the protection afforded me by the Florida Statutes regarding the suitability of this purchase. In addition, by not
  providing the requested information on this form, the company may not be able to process the application for the
  annuity in which I am applying.
  o I have chosen NOT to provide this information at this time.
  o I have chosen to provide LIMITED information at this time.
  o I have chosen to provide ALL information at this time.
  20. Was your decision to purchase this annuity based on your agent’s recommendation?                         o Yes o No
      By signing below, I acknowledge that:
        I
      •			reviewed	the	Customer	Identification	Notice	(form	number	10200)	and	agree	with	the	terms	of	the	notice.	
        T
  	 •		 he	information	I	provided	on	pages	1	through	3,	regarding	my	financial	status,	tax	status,	financial	objectives,	
        identification information and any other information requested by my agent is complete and accurate to the best
        of my knowledge.
        N
  	 •		 either	the	Company	nor	its	representatives	offer	legal	or	tax	advice	and	that	I	have	been	advised	to	consult	my	
        own personal attorney or tax advisor on any tax matters.
        T
  	 •		 he	annuity	I	am	applying	for	is	a	long	term	contract	with	substantial	penalties	for	early	withdrawal;	additionally	I	
        am aware that any withdrawals taken from the annuity may result in a taxable event.
        I
  	 •			understand	that	if	I	am	replacing	an	existing	annuity,	I	may	incur	a	surrender	charge	penalty,	that	I	may	or	may	
        not be able to overcome any penalty incurred and that I may or may not be able to reinstate the replaced contract(s).
        I
  	 •			believe	the	annuity	I	am	applying	for	is	suitable	according	to	my	insurance	needs	and/or	financial	objectives.
  APPLICANT / OWNER: DO NOT SIGN THIS FORM IF ANY ITEM HAS BEEN LEFT BLANK, BEFORE CAREFULLY
  REVIEWING THE INFORMATION RECORDED, OR IF ANY OF THE INFORMATION RECORDED IS NOT TRUE
  AND CORRECT TO THE BEST OF YOUR KNOWLEDGE.
  THE APPLICANT/OWNER AND/OR JOINT APPLICANT/JOINT OWNER MAY SUBSTITUTE THEIR INITIALS FOR
  SIGNATURES ON ALL FORM PAGES WITH THE EXCEPTION OF THE SIGNATURES BELOW, WHICH ARE
  REQUIRED.

  ___________________________________________________ ____________________________________________________________________________
  Applicant/Owner’s Signature                         Date Signed

  ___________________________________________________ ____________________________________________________________________________
  Joint Applicant/Joint Owner’s Signature             Date Signed




DFS-HI-1980 (Effective 10/25/2009)
17363 10/09 FL                                    *17363100905*                                 Adopted in Rule 69B-162.011, F.A.C.
                                                                                                                       Page 5 of 6
  Annuity Suitability Questionnaire

 EXPLANATION OF TERMS

“Age” is the natural person’s attained age on the day the form is completed.
“Annual household income” is the combined annual income received by all household members each calendar year.
“Annual income” is income received during a calendar year, whether earned or unearned.
“Form of Ownership” is the type of entity, other than a natural person, including a corporation, trust, partnership,
limited liability company, or other business or not-for-profit entity.
“Intended use of the annuity” means the purpose for which the senior consumer is considering the recommended
purchase or exchange. This may include the following: (1) Immediate income (within 60 days or less), (2) Tax Shelter
(protection from taxation of all types while in force), (3) Interest earnings, (4) Income stream at a stated age, (5)
Creditor Protection (a desire to protect assets from attachment by any legal process) (6) Other, as stated by the Senior
Consumer.
“Investment Objectives” are the senior consumer’s stated goals as described to the insurance agent or insurer, if no
insurance agent is involved. These may include but are not limited to the following: (1) Income, (2) Growth (long term
capital appreciation), (3) Safety of Principal and Income, (4) Safety of Principal and Growth, (5) To pass the investment
to a beneficiary or beneficiaries at death.
“Liquid Assets” are financial holdings that can readily be converted into their cash equivalent, without loss of
principal.
“Risk Tolerance” means the degree of uncertainty that an investor can reasonably tolerate with regard to a negative
change in his or her investments. Examples of risk tolerance levels may include the following: (1) Conservative (prefer
little or no risk), (2) Moderately conservative (some risk, reduced safety of principal), (3) Moderate (average risk with
potential losses and potentially higher returns),(4) Moderately aggressive (above average risk with potential losses,
risk of principal and potentially higher returns), (5) Aggressive (willing to sustain losses or loss of principal in pursuit of
higher returns).
“Source of annual income” is the income-generating source, such as pension income, dividends, or earned income etc.
“Source of the funds” to be used to purchase the proposed annuity means from where the funds will come to
purchase	the	annuity,	and	may	include	but	are	not	limited	to;	(1)	An	existing	annuity	or	life	insurance	contract,	(2)	Liquid	
Assets, including but not limited to, cash in banks, maturing certificates of deposit, and money market accounts, (3)
Personal Loans, (4) Equity Loans, (5) Mortgages, Reverse Mortgages, (6) Death Benefit Proceeds, (7) Funds received
upon retirement from employment, including but not limited to, 401(k) accounts, pensions, and other tax-sheltered
funds, (8) Equities, mutual funds, or bonds, (9) Proceeds from real estate transactions.
“Supporting documents” are the documents that provide a basis for the relationship between the Proposed
Annuitant, Joint Annuitant if applicable, and the Applicant/Owner as it may exist.
“Tax Status” is	the	senior	consumer’s	Federal	Income	Tax	filing	status	such	as	“single”	or	“married	filing	jointly”;	if	
“Exempt”, so state.
“Total Net Worth” is the senior consumer’s total assets minus total liabilities or encumbrances applicable to those
assets.

___________________________________________________ ____________________________________________________________________________
Applicant/Owner’s Signature                         Date Signed

___________________________________________________ ____________________________________________________________________________
Joint Applicant/Joint Owner’s Signature             Date Signed

DFS-HI-1980 (Effective 10/25/2009)
17363 10/09 FL                                   *17363100906*                                 Adopted in Rule 69B-162.011, F.A.C.
                                                                                                                      Page 6 of 6
                   Aviva Life and Annuity Company                                      Disclosure And Comparison
                   www.avivausa.com
                                                                                       Of Annuity Contracts
                                                       Please complete separate forms for any additional contracts being replaced.
                EXISTING ANNUITY CONTRACT                                             PROPOSED ANNUITY CONTRACT
Annuitant(s)                                                          Annuitant(s)
Owner                                                                 Owner
Insurer                                                               Insurer
Contract #                                                            Application #
                                                                Existing Annuity Contract               Replacement Annuity
Contract Issue Date (Est.)                                       Mo____ Day____ Yr____                 Mo____ Day____ Yr____
Generic Contract Type
Marketing Name
Initial Premium
Source of Initial Premium                                                                                           N/A
Qualified Contract?                                                       o Yes    o   No                       o Yes o No
Annuity Maturity Date
Death Benefit Amount
Change of Annuitant upon Death Available                                  o Yes    o   No                       o Yes     o   No
Surrender Charge Period in Years
First Year Surrender Charge Percentage Rate                                                    %                                       %
Surrender Charge Schedule for Remaining Years
Free Withdrawals Available?                                               o Yes    o   No                       o Yes     o   No
Annual Free Withdrawal Percentage Rate                                                         %                                       %
Waiver of Surrender Charge Benefit or Similar Benefit?                  o Yes     o   No                        o Yes    o    No
(List limitations, requirements, exclusions of the benefit)
Minimum Guaranteed Interest Rate                                                               %                                       %
Market Value Adjustment?                                                  o Yes    o   No                       o Yes     o   No
Asset Fees
Initial Bonus Percentage or Amount
Potential Loss of Bonus if Exchanged                                      o Yes    o   No                       o Yes     o   No
Limits and Exclusions for Bonuses that may be Payable
Interest Rate Cap
Participation Rate
Index Type
Administrative Fees or Margins
Writing Agent
Other_______________________________________________________________________________________
1. How will the replacement contract better assist you in meeting your insurance needs and financial objectives?
   o Lifetime Income Payout o Interest Rates/Index Credit Potential o Penalty-free Death Benefit
   o Change in Financial Objective o Enhanced Benefits o Increased Liquidity o Multiple Index Options
   Immediate Income Other - Please Explain _________    ___________________________________________________
2. Have you exchanged any annuities within the preceding 36 months? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o Yes o No
   If Yes, please explain ___________________________________________________________________________
_________________________________ __________                            _____________________       ____________ __________
Applicant/Owner Signature         Date Signed                           Joint Applicant/Joint Owner Signature    Date Signed
                                                                                                                 Adopted in Rule 69B-162.011,
DFS-HI-1981
17361 5/09 FL                                       *17361050901*                                                                       F.A.C.
                                                                                                                                   Page 1 of 4
                Aviva Life and Annuity Company                              Disclosure And Comparison
                www.avivausa.com
                                                                            Of Annuity Contracts

Disclosure Of Surrender Charges If
Existing Annuity Is Replaced Or Exchanged
Existing Annuity Contract No. _______________________
Annuity Total Valuei                          _
                             $________________ ______ Annuity Surrender Valueii $________________________  _
                                                                      _
Surrender Charges Applicable at exchange $______________________ ______
                     iii


This is the estimated amount that will be deducted from the existing annuity’s total value if surrendered,
replaced, or exchanged, with an anticipated surrender date of ______/______/________.
ACKNOWLEDGEMENTS AND SIGNATURES
Agent Acknowledgement
I acknowledge that I have provided the Applicant/Owner with a completed and signed copy of this form.
NOTE: NO QUESTIONS OR RESPONSE AREAS ARE TO BE LEFT BLANK WHEN OFFERED TO THE ANNUITANT,
APPLICANT/OWNER AND/OR JOINT APPLICANT/JOINT OWNER FOR SIGNATURE. IF ANY INFORMATION REQUESTED
IS UNAVAILABLE, NOT APPLICABLE OR UNKNOWN, THE INSURANCE AGENT MUST INDICATE THAT.

____________________________________________________ _______________________________________
Agent’s Name (please print)                          Florida License No.

____________________________________________________ _______________________________________
Agent’s Signature                                    Date Signed
Applicant/Owner Acknowledgement
THE APPLICANT/OWNER AND/OR JOINT APPLICANT/JOINT OWNER MAY SUBSTITUTE THEIR INITIALS FOR
SIGNATURES ON ALL FORM PAGES WITH THE EXCEPTION OF THE SIGNATURES BELOW, WHICH ARE REQUIRED.
APPLICANT/OWNER: DO NOT SIGN THIS FORM IF:
1. ANY ITEM HAS BEEN LEFT BLANK;
2. WITHOUT CAREFULLY REVIEWING THE INFORMATION RECORDED; OR
3. IF ANY OF THE INFORMATION RECORDED IS NOT TRUE AND CORRECT TO THE BEST OF YOUR KNOWLEDGE.
You should understand:
• You may or may not be able to overcome any surrender charge incurred due to the replacement of your existing contract.
• Once the existing contract is replaced, you may or may not be able to reinstate that contract.
• That the annuity you are applying for will have a withdrawal charge on any withdrawals over the free withdrawal amount
   provided in the contract during the withdrawal charge period.
I have reviewed and compared the contract provisions of the existing annuity contract to the annuity contract I am
applying for and believe this is appropriate for me according to my current insurance needs and financial objectives.

______________________________________________________
Applicant/Owner’s Name (please print)

______________________________________________________ ____________________________________
Applicant/Owner’s Signature                            Date Signed

______________________________________________________
Joint Applicant/Joint Owner’s Name (please print)

______________________________________________________ ____________________________________
Joint Applicant/Joint Owner’s Signature                Date Signed
                                                                                                  Adopted in Rule 69B-162.011,

DFS-HI-1981
17361 5/09 FL
                                             *17361050902*                                                               F.A.C.

                                                                                                                    Page 2 of 4
                 Aviva Life and Annuity Company                               Disclosure And Comparison
                 www.avivausa.com
                                                                              Of Annuity Contracts

Explanation Of Terms
“Administrative Fees or Margins” are charges that amount to the difference between the percentage gain in the index
 and the actual amount credited to the annuity contract.
“Annual Free Withdrawal Percentage Rate” is the percentage of available funds that may be withdrawn from an
 annuity contract, generally on an annual basis and is stated in the annuity contract.
“Annuity Maturity Date” is the final date of termination of the contract at which time the proceeds of the contract must
 be paid out.
“Asset Fees” are the fees the insurer charges that are a percentage of the value of the annuity contract.
“Change of Annuitant upon Death” is a provision that allows another person to become the annuitant upon the death
 of the original annuitant allowing the contract to remain in force.
“Death Benefit Amount” is the net amount that would be paid to the annuitant’s designated beneficiary or beneficiaries
 of an existing annuity, or the death benefit that the proposed replacement policy would pay as of the contract issue date.
“Free Withdrawals” are the withdrawals that may be taken from an annuity’s values that are not subject to surrender or
 other charges and are a provision of the annuity contract.
“Generic Contract Type” is the generic name of the annuity contract form as approved by the Florida Office of Insurance
 Regulation. Examples of generic annuity contract names are Flexible Premium Equity Indexed Annuity (FPEIDA), Single
 Premium Immediate Annuity (SPIA), Flexible Premium Variable Deferred Annuity (FPVDA), and Single Premium Deferred
 Annuity (SPDA).
“Index Type” is the financial measurement used by the insurer to make certain calculations within an annuity contract.
 Examples of such indices include Standard and Poor’s 500 and the Russell 2000.
“Initial Bonus Percentage or Amount” is a bonus paid by the insurer, generally, at inception of the annuity contract,
 and may be expressed as a percentage of the initial premium or other amount, or a dollar amount, and must be stated in
 the annuity contract.
“Initial Surrender Charge Percentage Rate” is the original percentage rate that is deducted from annuity values at the
 inception of the existing annuity contract, or that will be deducted from the recommended replacement contract at its
 inception if purchased.
“Interest Rate Cap” is the maximum interest earnings that will be credited to the annuity contract.
“Market Value Adjustment” is the increase or decrease in the surrender value of the contract that is adjusted to reflect
 market fluctuations.
“Marketing Name” is the name adopted by the insurer to identify the contract form.
”Minimum Guaranteed Interest Rate” is the minimum interest rate payable under the annuity contract as guaranteed
 by the insurer in the annuity contract.
“Participation Rate” is the percentage of the increase or return of the underlying stock market index that will be used to
 calculate the return.
“Potential Loss of Bonus if Exchanged” refers to whether any bonus would be lost if the annuity contract was
 exchanged or terminated for any reason.
“Qualified Contract” means a product used to fund any type of pension plan approved by the Internal Revenue Service.

_________________________________ ___________ _________________________________ ___________
Applicant/Owner Signature         Date Signed Joint Applicant/Joint Owner Signature Date Signed

                                                                                                     Adopted in Rule 69B-162.011,

DFS-HI-1981
17361 5/09 FL
                                              *17361050903*                                                                 F.A.C.

                                                                                                                       Page 3 of 4
                 Aviva Life and Annuity Company                                 Disclosure And Comparison
                 www.avivausa.com
                                                                                Of Annuity Contracts

Explanation Of Terms (continued)
“Surrender Charge” is the amount deducted from annuity contract values upon surrender of an annuity, or for withdrawals
exceeding any free withdrawal provision of the contract, regardless how this charge is titled in the policy, e.g., deferred sales
charge.
“Surrender Charge Percentage Schedule for Remaining Years” the percentage rate that would be deducted from
 the existing annuity contract if surrendered, or for any withdrawals exceeding the “free withdrawal” limit.
“Surrender Charge Period” is the number of annuity contract years a surrender charge may be applicable.
“Waiver of Surrender Charge Benefit or Similar Benefit or Provision” is a benefit that is built into individual annu-
 ity contracts or added by rider, endorsement or amendment. The benefits are triggered by a qualifying event associated
 with either the annuitant or owner, as specified in the contract.
i This amount represents the current value of the existing annuity, less any withdrawals or other deductions.
ii This amount represents the surrender value of the existing annuity.
iii Surrender charges or fees that will be deducted from #1 if you exchange or otherwise terminate your existing annuity.

_________________________________ ___________ _________________________________ ___________
Applicant/Owner Signature         Date Signed Joint Applicant/Joint Owner Signature Date Signed




                                                                                                        Adopted in Rule 69B-162.011,

DFS-HI-1981
17361 5/09 FL
                                                *17361050904*                                                                  F.A.C.

                                                                                                                          Page 4 of 4

								
To top