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Understanding the significance of the Jackson National Insurance form is crucial for insurance professionals seeking to establish a productive relationship with Jackson National Life Insurance Company and its affiliated agencies. This form serves not only as an application for insurance licensing appointments but also as a critical collection of pertinent personal and professional information about producers. Key sections of the form require applicants to provide their names, insurance license details, contact information, and their business relationships, whether through banks, credit unions, or independent channels. It requests specific data concerning the states where appointments are sought, as well as essential attachments such as copies of state licenses and the appropriate examination approvals. Importantly, the form also includes a Disclosure and Consent section, which highlights the importance of consumer report checks in the appointment process. Additionally, producers must be aware that a Background Investigation Questionnaire is part of the submission process, delving into applicants’ professional histories and any potential regulatory issues they might have faced. Together, these elements of the form not only streamline the appointment process but also ensure that the producer's qualifications meet the necessary criteria in compliance with regulatory standards.

Jackson National Insurance 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 [email protected]

 

Fax 303/689-2114

 

 

1 of 2

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)

2 of 2

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

File Breakdown

Fact Name Details
Producer Appointment Requirement Producers must complete the Jackson National Insurance form to obtain an insurance license appointment with Jackson National Life Insurance Company.
Contact Information The form requires contact information for the producer, including phone number, email address, and mailing address. This information is used for policy transactions and communications.
Background Investigation Producers authorize Jackson National to conduct a background investigation, which may include checking consumer reports and compliance with the Fair Credit Reporting Act.
State Guidelines Producers must indicate their resident state and any other states for appointment. Each state requires appropriate licensing and appointment by a broker/dealer.
Required Documentation Producers must provide copies of their active insurance licenses and any relevant NASD registration documents to obtain appointment approval.
Disclosure of Information Information shared during the appointment process may be disclosed to affiliates. The form outlines the types of information that may be shared and does not provide an opt-out option.

Guide to Using Jackson National Insurance

Completing the Jackson National Insurance form is essential for initiating your appointment with Jackson National Life Insurance Company. Follow these steps carefully to ensure all information is provided accurately, which will help expedite your application process.

  1. Begin by typing or neatly printing all requested information on the form.
  2. Enter your Broker/Dealer Name at the top of the form.
  3. Complete the Producer Information section, indicating how you market insurance products.
  4. Fill in your Full Name as it appears on your insurance license, followed by your NASD CRD No. and your Broker/Dealer ID No.
  5. Provide your Social Security Number (SSN), Date of Birth, and your Mailing Address for policy communications.
  6. Include your Business Telephone, Fax number, and E-Mail Address.
  7. If your business address differs from the mailing address, check the appropriate box describing the address type.
  8. Complete the Producer's Business Office Address section if necessary.
  9. List the states in which you seek appointment, ensuring you specify your resident state first.
  10. Indicate the preferred contact for any additional requirements or information needed.
  11. Ensure that all required documents, like copies of your insurance licenses and the Background Investigation Information Form, are attached to your submission.
  12. Read through the Disclosure and Consent section carefully. After understanding its implications, provide your printed name, signature, and date.
  13. Double-check the form for any missing information before mailing it to the specified address.

Once you have completed the form, submit it along with all necessary documents to the Jackson National Life Service Center, using either regular or overnight mail depending on your urgency. This step is vital for processing your application efficiently.

Get Answers on Jackson National Insurance

What is the Jackson National Insurance form used for?

The Jackson National Insurance form serves as an application for insurance producers who wish to be appointed with Jackson National Life Insurance Company. It collects essential information about the producer, their business affiliations, and their qualifications, ensuring that everything is in order for the appointment process.

What information do I need to provide on the form?

You’ll need to fill in various details, including:

  1. Your full name as it appears on your insurance license.
  2. Your contact information, including mailing address and phone number.
  3. Your insurance license details and any other relevant identifiers, such as your NASD CRD number.
  4. Information on how you market insurance products.
  5. States where you seek appointment.

Be sure to type or print clearly to avoid any confusion.

Are there any additional documents required with the form?

Yes, to complete your application, you'll need to provide several documents, including:

  • Copies of currently active state insurance licenses.
  • A NASD Central Registration Depository Status Report if applying for variable annuities.
  • A completed Disclosure and Consent Form.
  • A completed Background Investigation Information Form.

What happens if I answer "yes" to any questions on the Producer Background Questionnaire?

If you answer "yes" to any questions regarding complaints, disciplinary actions, or legal issues, you will need to provide additional details. Be honest and thorough in your explanations, as any misinformation could impact your ability to become appointed.

How long will the application process take?

The processing time can vary based on several factors, including the completeness of your application and background check results. Jackson National Life aims to handle applications swiftly, but it's always a good idea to check in with customer care if it seems to be taking longer than expected.

What do I do if I have questions about the form or the process?

If you have any questions, you can contact the Broker/Dealer Services at Jackson National Life. Their team is available via phone or email, providing assistance during business hours. It’s important to clarify any uncertainties before submitting your form to ensure all requirements are met.

Is my personal information kept confidential?

Yes, your information is treated with the utmost care. Jackson National Life has strict privacy policies in place to protect your data. They may share your information with affiliated companies to streamline the appointment process, but this is done under strict guidelines to ensure your privacy is respected.

Common mistakes

Filling out the Jackson National Insurance form can be a straightforward process, but mistakes are common and can lead to delays or issues with your application. One frequent error involves not including necessary personal information. It is imperative to provide all requested details such as your full name, Social Security Number, and date of birth as they appear on your insurance license. Omitting this information can lead to unnecessary complications.

Another common mistake is neglecting to check the correct boxes on the form. For example, accurately selecting how you market insurance products is essential for relationship management. Failing to do so can misrepresent your business practices and may impact your appointment status.

Many individuals also overlook double-checking their contact information. Providing an incorrect mailing address, phone number, or email could result in vital documents being sent to the wrong place. Ensure that all details are accurate and up to date to avoid communication breakdowns.

Additionally, some people mistakenly reference their previous insurance licenses or firm affiliations rather than their current ones. Using outdated information can confuse the review process, leading to delays in your appointment. Make sure to include only the current details to streamline your application.

The section asking for the states in which you request appointment often trips people up as well. It is crucial to confirm that your broker/dealer is licensed in these states. Misunderstanding this requirement may lead to unnecessary back-and-forth with the processing team.

Another issue arises from the failure to complete the Background Investigation Information Form accurately. The questions may seem straightforward, but discrepancies or incomplete answers raise red flags. It is essential to answer every question thoroughly to avoid jeopardizing your application.

Some applicants also forget to include required documents with their submission. For example, copies of active state insurance licenses and CRD status reports are critical for each state in which you seek an appointment. Missing these can halt the approval process.

Signature and date omissions are yet another common pitfall. There is a requirement to sign and date the form at the bottom. Without your acknowledgment, the application cannot be processed, causing unnecessary delays.

Lastly, overlooking the details of state-specific requirements can be problematic, especially for non-resident producers. Each state may have unique forms or regulations that must be adhered to. Familiarizing yourself with these can save time and effort in the long run.

Being mindful of these common mistakes can significantly improve the efficiency of your application process with Jackson National Insurance. Attention to detail is key. By taking the necessary time to ensure all information is correct and complete, you can help streamline your appointment experience.

Documents used along the form

The Jackson National Insurance form package includes several key documents that support the appointment process. Each document serves a distinct purpose, ensuring that all regulatory and compliance obligations are met. Below is a summary of these essential documents.

  • Producer Data Sheet: This is the primary form that collects information about the insurance producer, including personal details and experience in selling insurance products. It lays the foundation for the appointment application.
  • Copies of State Insurance Licenses: Producers must provide copies of currently active state insurance licenses, demonstrating their authority to sell variable contracts in the states they seek to be appointed.
  • NASD CRD U-4 Status Report: This report confirms a producer's passing of Series 6 or 7 examinations and is necessary for variable annuity appointments. It is typically obtained through the National Association of Securities Dealers.
  • Disclosure and Consent Form: This document requires producers to authorize Jackson National Life to conduct background checks, including reviews of consumer reports, as part of the appointment process.
  • Background Investigation Information Form: Producers complete this questionnaire, which entails providing personal history and disclosures regarding any relevant disciplinary actions, ensuring that the company has a clear picture of the applicant's background.
  • State Appointment Forms: These forms are necessary for non-resident producers, especially in states like Hawaii, and must be obtained from the broker/dealer's licensing unit.
  • Notice of Affiliate Information Sharing Practices: This notice informs producers of how their personal information may be shared with affiliated companies and details their rights regarding this sharing process.

These documents collectively facilitate a streamlined and thorough appointment process with Jackson National Insurance. Ensuring that all required forms are accurately completed and submitted helps avoid delays in your application.

Similar forms

  • Insurance Application Form: Similar to the Jackson National Insurance form, an insurance application form collects personal and professional information from agents before they can work with an insurance company. Both documents require details such as the applicant's name, address, and licensing information.
  • Broker-Dealer Registration Form: This document is used for registering with the securities industry, similar to how the Jackson National Insurance form serves for insurance licensing. Both require identification information, background checks, and details on any prior disciplinary actions.
  • Background Investigation Consent Form: Like the disclosure sections in the Jackson National Insurance form, this document permits an organization to conduct background checks. Both forms contain information about the nature of the background investigation and the applicant's rights.
  • State Insurance License Application: This form, used by insurance agents to obtain licensure, shares key similarities with the Jackson National Insurance form. Both documents require personal identification, proof of education or training, and affirmation of the applicant’s willingness to abide by regulatory standards.
  • Financial Services License Application: In the financial industry, this application is akin to the Jackson National form for agents seeking insurance appointments. Both require detailed financial disclosures, regulatory compliance confirmations, and contact information for background checks.

Dos and Don'ts

When filling out the Jackson National Insurance form, there are several crucial guidelines to follow. These will help ensure that your application is processed smoothly and efficiently. Here are some dos and don'ts:

  • Do type or print all requested information clearly.
  • Do provide accurate and complete responses to every question.
  • Do include copies of all required documents, such as your active state insurance license.
  • Do ensure your contact information is up-to-date for effective communication.
  • Don't leave any sections blank; incomplete forms may delay your application.
  • Don't use non-standard abbreviations or symbols that could confuse the reviewer.
  • Don't omit any necessary signatures or dates, as these are critical for validation.
  • Don't rush through the form; take your time to double-check for errors.

Misconceptions

  • Misconception: The Jackson National Insurance form is only for new producers. Many believe that this form is exclusively designed for individuals entering the insurance industry. In reality, it is also applicable to existing producers seeking to establish appointments with Jackson National Life Insurance Company or its affiliated entities.
  • Misconception: Completing the form is a guarantee of approval. Some producers think that submitting the form guarantees their appointment. However, completion of the form does not assure acceptance. Jackson National will conduct further evaluations, including background checks, before finalizing any appointments.
  • Misconception: Only producers from certain states can apply. It is common to assume that only producers who reside in specific states are eligible to complete the form. While state residency is a factor, producers from multiple states can apply as long as they meet licensing requirements in those states.
  • Misconception: The form requires an extensive array of documents and is overly complex. Many individuals believe the paperwork is daunting. Although the form requires specific documents, such as licensing information and background checks, it is straightforward when all necessary materials are organized. Clear instructions accompany the form to facilitate the process.

Key takeaways

Filling out and using the Jackson National Insurance form requires careful attention to detail. Here are key takeaways to ensure a smooth application process:

  • Complete the Application Accurately: Type or print all requested information clearly. Ensure accuracy to avoid delays.
  • Include Required Documents: Attach copies of your active state insurance licenses and your NASD CRD Status Report, if applicable.
  • Select Appropriate Sales Channels: Indicate how you market insurance products, whether through banks, credit unions, or non-bank relationships.
  • Check Address Accuracy: Make sure to confirm whether the provided address is your business office, residence, or another location.
  • Understand State Appointment Requirements: Verify that your broker/dealer is also licensed in the states for which you are requesting appointment.
  • Obtain Necessary Signatures: Ensure that both the Disclosure and Consent Form and the Background Investigation Information Form are signed and dated.
  • Update Information Promptly: Notify Jackson National of any changes such as criminal convictions or changes in personal information that occur after submission of the form.
  • Keep a Record: Retain copies of all submitted forms and documentation for your files as a reference.
  • Contact for Assistance: If questions arise, reach out to the JNL Customer Care or your broker/dealer's licensing unit for guidance.