Jackson National Life Insurance Forms

Producer Data Sheet

Please type or print all requested information.

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

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):

Full Name (as it appears on your insurance license)

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

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

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

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:

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

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.

Producer Background Questionnaire

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.)

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

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

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?

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?

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?

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

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?

6.) Have you ever been involved in a bankruptcy (personal or otherwise), had a salary garnisheed or had liens or judgments against you?

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

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

Details

Notice of Affiliate Information Sharing Practices and Opt-Out Opportunity

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.