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You would likely be better off without this form than with it. It makes it look like you're trying to CYA...
I'm not an attorney, but I am at a Holiday Inn Express right now.
I have kicked around the idea of my own secondary disclosure forms for clients to sign in certain circumstances, but never pulled the trigger.
For those of you who are familiar with the Glenn Neasham "criminal charges for selling an annuity" fiasco, one thing that the prosecution made a big deal about was the additional disclosure he had the client sign. The argument was "if you are doing right, then why would you feel the need for more disclosures when the client already signs multiple ones already?"... "Why would an honest person, in a reasonable situation, need disclosures signed above and beyond what the state has already approved as being enough?"
After seeing how it worked against him in court. I opt for the standard state approved carrier paperwork.