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Producer Background Questionnaire |
Jackson National Life |
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Business Through Broker/Dealer and/or Broker/Dealer Affiliated Agency |
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Insurance Company |
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For Insurance License Appointment with Jackson National Life Insurance Company |
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and Jackson National Life Distributors, Inc. Member NASD. |
Home Office: Lansing, Michigan |
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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) |
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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.)
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Previous Residence Address (Street, City, State, ZIP) |
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Previous Residence Address (Street, City, State, ZIP) |
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1.) |
Have you ever been the subject of any complaint (including a customer complaint) or proceeding by any insurance, securities, or |
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..................................................................................................................commodities regulatory body or organization? |
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No |
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Yes |
2.) |
Have you ever been suspended, expelled, terminated, fined, barred, censured, or otherwise disciplined or found to have violated |
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any insurance, securities or commodities law or rule by any insurance, securities or commodities regulatory body or organization |
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...............................................................................or an employer in the insurance, securities or commodities industry? |
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No |
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Yes |
3.) |
Have you ever been refused a license to sell insurance or been refused membership in any securities or commodities regulatory |
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body or organization or had a license suspended or revoked by any State Insurance Department or by any securities or |
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commodities regulatory body or organization? |
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No |
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Yes |
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4.) |
Have you ever been convicted of, or pleaded guilty or nolo contendere to, any felony or misdemeanor? |
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No |
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Yes |
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5.) |
Have you ever had your employment arrangement terminated, or have you been “permitted to resign” from any insurance |
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.................................................................................................................company or other financial services employer? |
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No |
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Yes |
6.) |
Have you ever been involved in a bankruptcy (personal or otherwise), had a salary garnisheed or had |
liens or judgments against |
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you? |
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No |
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Yes |
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7.) |
Are there any lawsuits, judgments or liens pending against you? |
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No |
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Yes |
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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.