X____________________________________________________________ X____________________________________________________________ Sample Clauses
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X____________________________________________________________ X____________________________________________________________. First Name Listed Below Will Be The Servicing Producer ------------------------------------------------------------------------------------------------------------------------------------ PHONE NUMBER FAX NUMBER SERVICING PRODUCER COMM PRODUCER NAME (INCLUDE AREA CODE) E-MAIL ADDRESS (INCLUDE AREA CODE) OFFICE # CODE % ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ Broker Dealer Name______________________________________________________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------ REMARKS - IDENTIFY QUESTION AND GIVE DETAILS ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ▇▇-▇▇▇▇▇-▇▇ 10/2003 Pacific Life & Annuity Company [LOGO OF PACIFIC LIFE] ▇.▇. ▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇ DISCLOSURE NOTICE TO BE DETACHED AND LEFT WITH THE PROPOSED INSURED(S) This is a brief description of our underwriting process ("process"). It will help you understand how an application for insurance is handled, the types and sources of information ("data") we may collect about you, the circumstances under which we may disclose that data to others and your right to learn the nature and substance of that data. The purpose of the process is to see if you qualify for insurance under our rules, and if you do, to establish the proper premium charge. This w...
