Jackson National Insurance Form PDF Details

Jackson National Insurance Form is a requirement for all individuals who are looking to purchase insurance from the company. The form can be found on the Jackson National website and must be completed in full before any coverage can be issued. The form is short and simple, but provides all of the information necessary for the company to assess your risk and determine what level of coverage is appropriate for you. Completing the form accurately is critical, as it will be used to set your premiums. Be sure to consult with an agent if you have any questions about what information should be included.

Below are some facts you may want to examine prior to starting using the jackson national insurance form.

QuestionAnswer
Form NameJackson National Insurance Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesjackson withdrawal form, jackson life insurance claim form, jackson national appointment form, jackson national life insurance company forms

Form Preview Example

Producer Data Sheet

Jackson National Life

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

Insurance Company

For Insurance License Appointment with Jackson National Life Insurance Company

 

and Jackson National Life Distributors, Inc. Member NASD.

Home Office: Lansing, Michigan

 

 

www.jnl.com

Please type or print all requested information.

 

 

 

Broker/Dealer Name

 

 

 

Producer Information

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

In a bank/credit union lobby

 

Through a working relationship with a bank/credit union

Through non-bank relationships

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

Your NASD CRD No.

Your ID No. issued by your Broker/Dealer

SSN (include dashes)

Date of Birth (mm/dd/yyyy)

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

Business Telephone (include area code)

Fax (include area code)

E-Mail Address

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

Producer's OSJ or Branch Office other than place of business

 

Residence

 

Other(specify)

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

States in which you request appointment:*

Resident state (required):

 

Others:

 

 

 

,

 

 

 

,

 

 

 

,

 

 

 

,

 

 

 

,

 

 

 

,

 

 

 

,

 

 

 

,

 

 

 

,

*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:

Producer

 

Broker/Dealer or Affiliated Agency

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

Mailing Address and Contact Information

Regular Mail:

Broker/Dealer Services

 

Jackson National Life Service Center, P.O. Box 17240, Denver, CO 80217-0240

Overnight Mail:

Jackson National Life Service Center, 8055 E. Tufts Ave., 2nd Floor, Denver CO 80237

Customer Care:

800/565-8798 (9:00 a.m. to 7:00 p.m. ET) or customercare@jnli.com

 

Fax 303/689-2114

 

 

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V5827 10/04

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

Signature

Date (mm/dd/yyyy)

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V5827 10/04

Producer Background Questionnaire

Jackson National Life

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

Insurance Company

For Insurance License Appointment with Jackson National Life Insurance Company

 

and Jackson National Life Distributors, Inc. Member NASD.

Home Office: Lansing, Michigan

 

 

www.jnl.com

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.

Producer Name

SSN (include dashes)

 

 

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.)

From (mm/dd/yyyy)

 

to (mm/dd/yyyy)

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From (mm/dd/yyyy)

 

to (mm/dd/yyyy)

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From (mm/dd/yyyy)

 

to (mm/dd/yyyy)

 

 

 

.

 

 

 

 

 

1.)

Have you ever been the subject of any complaint (including a customer complaint) or proceeding by any insurance, securities, or

 

..................................................................................................................commodities regulatory body or organization?

 

 

 

No

 

Yes

2.)

Have you ever been suspended, expelled, terminated, fined, barred, censured, or otherwise disciplined or found to have violated

 

any insurance, securities or commodities law or rule by any insurance, securities or commodities regulatory body or organization

 

...............................................................................or an employer in the insurance, securities or commodities industry?

 

 

 

No

 

Yes

3.)

Have you ever been refused a license to sell insurance or been refused membership in any securities or commodities regulatory

 

body or organization or had a license suspended or revoked by any State Insurance Department or by any securities or

 

 

 

commodities regulatory body or organization?

 

 

 

 

No

 

Yes

 

 

 

 

 

4.)

Have you ever been convicted of, or pleaded guilty or nolo contendere to, any felony or misdemeanor?

 

 

No

 

Yes

.....................

 

 

 

 

 

 

 

5.)

Have you ever had your employment arrangement terminated, or have you been “permitted to resign” from any insurance

 

 

 

.................................................................................................................company or other financial services employer?

 

 

 

No

 

Yes

6.)

Have you ever been involved in a bankruptcy (personal or otherwise), had a salary garnisheed or had

liens or judgments against

 

you?

 

 

 

 

 

 

 

 

No

 

Yes

 

 

 

 

 

 

 

 

 

 

7.)

Are there any lawsuits, judgments or liens pending against you?

 

 

 

 

No

 

Yes

 

 

 

 

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.

Signature

Date (mm/dd/yyyy)

V5836 10/04

Jackson National Life Insurance Company

Jackson National Life

Insurance Company

 

Notice of Affiliate Information Sharing Practices and Opt-Out Opportunity

Home Office: Lansing, Michigan

www.jnl.com

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.

V5540 10/04

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