Producer Data Sheet at a glance
What it is: The Producer Data Sheet is for Insurance License Appointment with Jackson National Life Insurance Company through a Broker/Dealer and/or Broker/Dealer Affiliated Agency.
Who signs: Producer: enter your Printed Name and the Date (mm/dd/yyyy), and sign on the Signature line.
What to bring and attach to Producer Data Sheet
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.
The 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; this report is only required if applying for variable annuity appointment.
Disclosure and Consent Form completed, signed and dated.
Background Investigation Information Form completed, signed and dated.
Non-resident Hawaii producers are required to sign the state appointment form.
A filled-in Producer Data Sheet example: a producer fills out page 1
How to fill out Producer Data Sheet, box by box
Broker/Dealer Name
Type or print all requested information.
Enter the Broker/Dealer Name.
Producer Information
Under Producer Information, enter your Full Name as it appears on your insurance license (last, first, middle initial).
Enter Your NASD CRD No.
Enter Your ID No. issued by your Broker/Dealer.
Enter your SSN (include dashes).
Enter your Date of Birth (mm/dd/yyyy).
Enter the Mailing Address for policies and policy transaction confirmation statements (Street or P.O. Box, City, State, and ZIP).
Enter the Business Telephone and Fax, include area code.
Enter the E-Mail Address.
States in which you request appointment
Under States in which you request appointment, enter your Resident state (required) and Others.
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.
More rules for Producer Data Sheet
Under Non-Bank/Bank Sales, check those that apply to how you market insurance products: In a bank/credit union lobby, Through a working relationship with a bank/credit union, Through non-bank relationships.
If the address is not the producer's business office, check the box that describes the address: Producer's OSJ or Branch Office other than place of business, Residence, Other(specify).
Enter the Producer's Business Office Address (Street or P.O. Box, City, State, ZIP) if different.
Contacts: in the event additional items are needed in order to complete the appointment, JNL should contact the Producer or the Broker/Dealer or Affiliated Agency.
Also complete the reverse side of this form and the Background Investigation Information Form enclosed.
Print or type all requested information, answer all questions, and sign and date the form.
Incorrect or incomplete responses may jeopardize your ability to become appointed with JNL.
Enter the Producer Name and SSN (include dashes).
Enter your Current Residence Address (Street, City, State, ZIP) and how long at that address. If less than seven years, provide a seven-year address history or attach a separate sheet.
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 or 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 or 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 or 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 or 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 or Yes)
4.) Have you ever been convicted of, or pleaded guilty or nolo contendere to, any felony or misdemeanor? (No or Yes)
7.) Are there any lawsuits, judgments or liens pending against you? (No or Yes)
For any "Yes" answers, you must provide details, referencing the question number. Attach additional sheets if necessary.
Common questions about Producer Data Sheet
Who signs it?
Producer: by signing you acknowledge that you have read and understand the preceding information and certify, under penalty of perjury, that the information provided on this part of the form and on any attached sheets is true, correct and complete. Enter the Date (mm/dd/yyyy) and sign on the Signature line.
Where do I file it?
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.
What am I certifying when I sign?
By signing, you acknowledge that you have read and understand the preceding information and certify, under penalty of perjury, that the information provided on this form is true, correct and complete.
Sources
[1] Producer Data Sheet (V5827 10/04), Jackson National Life Insurance Company (the Official source link on this page).
