Jackson National Insurance Form – Fill Out and Use This PDF

Producer Information

Non-Bank/Bank Sales: For relationship management and distribution channel purposes, please tell us how you market insurance products ( those that apply):

Through non-bank relationships

Full Name (as it appears on your insurance license) ( last, first, middle initial)

Mailing Address (for policies and policy transaction confirmation statements) (Street or P.O. Box, City, State, and ZIP)

If the address noted above is not the producer's business office, please check ( ) the box that describes the address:

Producer's Business Office Address (if different than above) (Street or P.O. Box, City, State, ZIP)

States in which you request appointment:*

*Please note that your broker/dealer or its affiliated agency must also be properly licensed and appointed with JNL in these states. Please check with your broker/dealer or its affiliated agency if you have questions.

Contacts: In the event additional items are needed in order to complete the appointment, JNL should contact the:

Please also complete the reverse side of this form and the Background Investigation Information Form enclosed.

Mailing Address and Contact Information

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Producer Data Sheet

Business Through Broker/Dealer and/or Broker/Dealer Affiliated Agency

Please include the following required documents:

Copies of currently active state insurance license(s) showing state-appropriate variable contracts authority (if applicable) for each state in which you request appointment.

NASD Central Registration Depository (CRD) U-4 Status Report indicating Series 6 (IR) or 7 (GS) examination approval and Uniform State Securities Registration (AG) in each state in which you request appointment. Please contact your broker/dealer if you have questions regarding this registration. JNL can obtain this information from the NASD Internet Web site with your CRD number if the Status Report is not readily available. This report is only required if applying for variable annuity appointment.

Disclosure and Consent Form completed, signed and dated (Please see below). Background Investigation Information Form completed, signed and dated (enclosed).

Non-resident Hawaii producers are required to sign the state appointment form. Please contact your broker/dealer's (or its affiliated agency's) licensing unit to obtain the Hawaii non-resident appointment form, or call us at the number listed on reverse side.

Disclosure and Consent

We thank you for showing interest in Jackson National Life Insurance Company ("JNL") and assure you that your application will be processed as quickly as possible. By signing below, you acknowledge and agree that JNL may order "consumer reports" or "investigative consumer reports" in making a routine investigation to provide information concerning your licensing, character, general reputation, personal characteristics, mode of living and financial condition. The investigation may also include information compiled by the National Association of Securities Dealers, Inc. Central Registration Depository. You herewith authorize JNL to provide the information it obtains about you in any consumer report to its affiliated companies and/or third parties, where it or affiliate's legal interests or obligations are involved and agree to hold JNL and its affiliates harmless from liability for any and all consequences of relating such information. This authorization is effective with regard to your application for appointment with JNL and continues throughout any period of appointment. Upon written request addressed to Broker/Dealer Services, Jackson National Life Insurance Company, P.O. Box 17240, Denver, CO 80217-0240, additional information as to the precise nature and scope of the investigation, if one is made, will be provided. This notification is in accordance with the Fair Credit Reporting Act (Public Law 91-508).

By signing below, you acknowledge that you have read and understand the preceding information and certify, under penalty of perjury, that the information provided below and on the reverse side of this form is true, correct and complete.

Printed Name

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Please print or type all requested information, answer all questions, and sign and date the form. Please include it with your JNL Producer Data Sheet and Disclosure and Consent Form. Note that JNL reviews all NASD Disciplinary Actions and may perform a criminal background investigation. Incorrect or incomplete responses may jeopardize your ability to become appointed with JNL.

Current Residence Address (Street, City, State, ZIP)

How long at above address? (If less than seven years, provide seven-year address history below or attach separate sheet.)

For any "Yes" answers above, you must provide details in the space below, referencing the question number. Attach additional sheets if necessary.

Producer agrees to immediately notify JNL of the occurrence of any of the following events:

a)The producer is convicted of, or pleads guilty or nolo contendere to, any felony;

b)The producer is convicted of, or pleads guilty or nolo contendere to, any misdemeanor or other legal action, whether civil or criminal, involving a breach of trust including, but not limited to: forgery, fraud, false statements or omissions, perjury, misappropriation, embezzlement, larceny or burglary;

c)The producer ceases to possess the requisite qualifications or licenses to conduct the activities contemplated herein;

d)The producer changes his/her address of record as previously provided and on file with the Company.

The producer shall also provide JNL with a legible copy of the insurance license issued to him or her by each state in which he or she is, or becomes, appointed with JNL. Producer shall provide a copy of each such license prior to, or in conjunction with, each appointment sought with JNL. Producer shall also provide a copy of each such license when received by the producer, in the event of state license renewal, and as may be reasonably requested by JNL.

By signing below, you acknowledge that you have read and understand the preceding information and certify, under penalty of perjury, that the information provided above and on any attached sheets is true, correct and complete.

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Jackson National Life Insurance Company recognizes that you expect us to protect the information you provide us about yourself, as well as the information about you that we gather (“Background Information”) during the background check we conduct as part of the appointment process. We are strongly committed to fulfilling the trust that is the foundation of your expectations. For this reason, we want to make you aware that we may share your Background Information with some of our affiliated financial services companies in relation to your appointment, licensure or registration with them. This sharing saves our companies the cost of what often would amount to a duplication of a previous background check, and saves time in the processing of the appointment and related matters, hopefully allowing you to begin producing business more quickly. For the reasons above, we have adopted and adhere to the following policy regarding the privacy of your personal information.

INFORMATION WE MAY SHARE WITH OUR AFFILIATES

We collect the following types of nonpublic personal information about you, which we may share with our affiliates:

•Information we receive from you on the application for appointment (the Producer Data Sheet);

•Information about you that we receive from consumer reporting agencies, including information regarding your credit history, prior employment, and criminal history, if any;

•Information about you that we obtain to verify background information you have provided, such as through personal contacts with prior employers; and

•Information regarding your professional designations, registrations, licenses and appointments, from industry regulatory agencies or service providers such as the National Insurance Producer Registry and the National Association of Securities Dealers, Inc.

AFFILIATES WITH WHOM WE MAY SHARE INFORMATION

To the extent permitted by law, we may disclose any of the nonpublic personal information we collect, as identified above, with our affiliates. Examples of affiliates with whom we may share your nonpublic personal information include financial services providers, such as our affiliated life insurance companies, banking organizations and securities broker/dealers and investment advisers.

ABILITY TO OPT OUT OF THE INFORMATION SHARING

Internally, your information is only available to those employees requiring access to process your appointment, registration, or licensure request and those fulfilling other necessary functions on our behalf. We only share your information in circumstances where it is our belief that doing so presents time and/or cost efficiencies to our companies and, in many cases, to you as well. For this reason, Jackson National Life Insurance Company does not provide a mechanism for you to opt out of the information sharing with affiliates. If you do not wish Jackson National Life Insurance Company to share your nonpublic personal information with our affiliated financial services companies, you should not proceed to submit the appointment, registration or licensure request to us.

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