LICENSING AND CONTRACTING

Transcription

1 LICENSING AND CONTRACTING THANK YOU FOR CONTRACTING WITH ONE OF OUR CARRIERS! PLEASE COMPLETE THE ATTACHED APPOINTMENT PACKET & THIS SHEET. THEN, MAIL, FAX OR TO YOUR ASSIGNED REPRESENTATIVE: Brokers Alliance, Inc. P.O. Box Fountain Hills, AZ ** FAX TOLL-FREE TO: (866) ** Anti-Money Laundering Training Requirement* AML training was completed via LIMRA on / / ; or, AML training was completed via an independent program (completion certificate attached). *If you have not met your AML training requirement, please visit our website for the LIMRA training link. Please identify your CURRENT APPOINTMENTS with other carriers Some carriers may require a release for appointment under Brokers Alliance, Inc. Please indicate your Representative below. If you have any questions, CALL TOLL-FREE: (800) ANNA BANKS x112 HOLLY CHIN x123 MARK GRAHAM x120 AARON GRAVEL x141 DAVE LaBOUNTY x128 JESSICA LOPEZ x106 CAYSE MERSCH x108 ERIC PALMER x103 MATT PROVOST x115 DAVID RACICH x111 RANDY ROBERTS x107 JOHN WALLACE x130 LISA WINK x117 Brokers Alliance Communication Brokers Alliance distributes carrier product updates, licensing notices and case status memos via notification. Please provide us with a valid address below permitting us to send such updates and notices. Please check this box permitting Brokers Alliance to send communication to the below address: Address** ** By not providing us with your address, there is no way for Brokers Alliance to communicate carrier product updates, case management status, Brokers Alliance commission/bonus changes and much more.

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19 COMMISSION ADVANCING SECURITY FORM AUTHORIZATION TO CHARGE SUMS TO CREDIT CARD Brokers Alliance, Inc. has agreed to guarantee the obligation(s) of the undersigned to repay loans, advances of commissions and/or overpayment of commissions made by various insurance companies to the undersigned. In the event at any time in the future Brokers Alliance, Inc. pays any of the aforesaid obligations, the undersigned agrees to reimburse Brokers Alliance, Inc. for the sums paid by Brokers Alliance, Inc. and further agrees that Brokers Alliance, Inc. shall have the right and is hereby authorized to charge the credit cards identified below as a nonexclusive method of receiving payment for said sums. The undersigned acknowledges that said sums may be charged at any time after Brokers Alliance, Inc. pays the obligation and acknowledges that payment by Brokers Alliance, Inc. may not be made for several years after the obligation is incurred by the undersigned. The undersigned hereby waives any statute of limitations with regard to sums owed by the undersigned to Brokers Alliance, Inc. and agrees that, in the event of nonpayment by the undersigned, Brokers Alliance, Inc. may report said obligation as unpaid to any credit bureau or reporting agency. The undersigned agrees to immediately notify Brokers Alliance, Inc. in the event that any of the credit cards listed below are revoked, surrendered, terminated or credit is no longer available under said cards. The undersigned further agrees to provide all updated information relative to said credit cards immediately upon any change of information, including any replacement or expiration of said card. In the event that the undersigned contests any charge made to any such card and the charge is deemed valid, the undersigned shall reimburse Brokers Alliance, Inc. for all costs and fees, including attorneys fees, associated with such contest.

20 Because this authorization relates to an on-going guarantee of a commercial obligation, the undersigned agrees that this authorization shall be irrevocable. Date Signature Printed Name Card One (Required) Type of Card: VISA Mastercard Card Number: Expiration Date: Security Code: Name on Card: Billing Address: Cardholder Signature: Card Two (Required) Type of Card: VISA Mastercard Card Number: Expiration Date: Security Code: Name on Card: Billing Address: Cardholder Signature:

21 Debit Balance & Advance Commission Agreement (Choice of Law-Arizona) This Agreement is by and between Joseph Racich (aka Brokers Alliance, Inc.) with his principal place of business in Maricopa County in the state of Arizona and, with his/her/its principal place of business in (hereinafter called Agent ). This Agreement shall be applicable to every insurance company with whom the undersigned Agent is contracted and/or appointed and Joseph Racich is the Agent s upline. Whereas, agent has attested in writing to Joseph Racich all current personal liens as well as debts with all insurers, if any and agent desires to be exempt from an escrow account or bond to guarantee payment of any future debit balance, if any and/or desires commission advancing, if eligible, from insurance companies represented through Joseph Racich: Now Therefore, for good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties do hereby agree as follows: 1. Agent agrees to pay to the order of the appropriate insurance company and/or to Joseph Racich the sum of any indebtedness resulting from unearned advances, any remuneration, special advances, any fees, chargebacks of any kind, interest or any other charges to the Agent s commission account. 2. Within thirty (30) days written notice of demand to the agent s last mailing address on record with insurance company for payment of any indebtedness to the insurance company and/or Joseph Racich, Agent agrees to immediately pay indebtedness in full, by cash, money order or certified funds. 3. Agent also agrees and understands any unearned commissions and renewals are not an acceptable form of payment in the event demand has been made for any indebtedness. Any case involving a refund of premium, regardless of cause, Agent agrees to immediately remit payment, in full, to clear indebtedness. 4. In the event an insurer holds Joseph Racich financially responsible for any Agent indebtedness or any other fees or monies as a result of past indebtedness and Joseph Racich finds it necessary to enforce payment through legal action, Agent agrees to pay reasonable legal fees and court costs incurred by Joseph Racich and hold Joseph Racich harmless from and against any such liability. Additionally, if it becomes necessary to refer this matter to a collection department, agency or result in a filing of a complaint to the department of insurance regarding the return of any unearned monies 35% will immediately be added to the principal balance. 5. Agent agrees to assign, without contest, any commissions and renewals with other insurance companies, present and future, to Joseph Racich if any agent indebtedness, secured or unsecured, remains after 90- days of the debt occurrence. Assignments shall remain effective until all agent debts are cleared. 6. Both parties agree the enforcement of this Agreement shall be subject to the jurisdiction of the proper courts of Southlake, Tarrant County, Texas and construed pursuant to the laws of the State of Texas. This Agreement shall survive the termination of all contractual/appointment relationships between Agent and the insurance companies represented through Joseph Racich. Agent irrevocably authorizes Joseph Racich or any attorney of any court of record, after default, to confess a judgment without process against Agent in favor of Joseph Racich and waives all errors in such proceedings and consents to immediate execution upon said judgment. This Agreement shall be a continuing one and shall remain in full force and effect until written notice from Joseph Racich is received and until all debt and liability arising hereunder has been fully paid. I have read the foregoing and agree to be bound by the terms and conditions set forth herein. Agent Signature Agent Printed Name Date Personal Guarantee Signature, if Corporation AGREED, ACCEPTED and APPROVED by Joseph Racich in Maricopa County, Arizona. Joseph Racich Doc/Debit Balance and Advance Commission Agreement Date

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