General Contract Checklist for General Agent. Required Documents for Contracting

Transcription

1 General Contract Checklist for General Agent Agent Name: FAX TO: Required Documents for Contracting General Agent Agreement o Signature Page o Current E&O Declarations Page o Current State License for selected carriers o Agent Information Completed Entirely o Tax Identification W9 Completed o SSN, NPN, & Hierarchy Completed Background & Information Sheet o Any questions answered YES requires a written, signed, and dated explanation Commissions Deposit Authorization o Direct Deposit Form Completed o Voided Check for account to be paid- Agent or Agency

2 Social Security # AGENT INFORMATION Full Name LAST FIRST MIDDLE SUFFIX TITLE NPN # Sex Date of Birth Primary Phone Secondary Phone Fax # BUSINESS ADDRESS Agency Name Street (For mailing purposes only) PO Box City State ZIP County SHIPPING ADDRESS (must be street address) Same as Business Address Yes No Agency Name Street (For mailing purposes only) PO Box City State ZIP County RESIDENT ADDRESS Street Length of time at Resident Address(Months/Years) PO Box City State ZIP County BUSINESS INFORMATION # of years selling insurance(months/years) List the name(s) of other Insurance Companies you represent ** Address: AGENT OR AGENCY AFFILIATION (Name of agent or agency you are working with, if applicable.) Name Fed.Tax ID # or SS # Address Commission Payments If directing your commissions to an agency, be sure to send in their voided check/dd info. Otherwise, please include your voided check/dd info. Marital StatusName of Spouse: **PLEASE INCLUDE YOUR CURRENT ADDRESS! This will be an important method of contact between you & your Marketer, as well as vital to your contracting process. Direct Deposit If you would like to sign up for Direct Deposit of your commissions, please complete the Direct Deposit form (Appendix, page 33). 3

3 Please list any and all carriers that you have been appointed and/or done business with: FROM Mo/Yr TO Mo/Yr CARRIER NAME STATE ACTIVE? BACKGROUND QUESTIONS A. Are you presently indebted to any insurer or any insurance company or managing Yes No general agent? B. Are there any criminal charges pending against you? Have you ever: Yes No C. D. been the subject of any investigation or proceeding by any insurance department? had any agency contract or company appointment canceled for cause (e.g. misrepresentation, misappropriation, etc.)? E. been suspended, expelled, fined, barred, censured or otherwise disciplined or found to have violated any law or rule by any insurance department or by any party in the insurance industry? F. been refused a license to sell insurance or membership in any organization or had a license suspended or revoked by any insurance department? G. withdrawn any application or surrendered any license to avoid any disciplinary action or the denial of a license? H. been convicted of or pleaded nolo contendere to any felony or misdemeanor, except I. for traffic offenses? If yes, give complete information and attach copy of court order. gone through bankruptcy, had salary attached or had any liens or judgements outstanding against you? J. been named a party in any lawsuit? K. been fined suspended, placed on probation, paid administrative costs, entered into a consent order, been issued a restricted license or otherwise been disciplined or reprimanded, or are you currently under investigation by any insurance department, the NASD, SEC or any other regulatory authority? L. Are you requesting the receipt of commission on an advance basis? M. Are you listed with Vector One? Name of company, debit balance N. Have you completed Anti-Money Laundering training in the last 12 months? (If yes, please include a certification of your completion) O. Are you a Broker Dealer? P. Does any insurance or financial services company hold a claim against you for commission debit balances? For any Yes answers, please attach a detailed explanation. ENCLOSE a copy of your state insurance license and/or appropriate state appointment form for the state(s) in which you will be selling. C o v e r p a g e s f o r a ll f o rm s a v a i la b le u p o n re q u e st. Yes No

4 Carrier Selection: Please select which carriers below you d like to be appointed with through Messer Financial Group Carrier Name E&O Required Direct Deposit Required Aetna Y N Allianz N Y American Continental N N American Equity Y N American Family Life Assurance Company N N American General- Life Brokerage Y Y American National Y N Americas 1 st Choice N N Americo Y Y Assurant Health Y N Assurity Life Insurance Company Y Y Athene Annuity & Life Assurance Company Y N Aviva Life & Annuity Company Y N Aviva Life & Annuity Company-Annuity Y N Banner Life Y N BCBS-Georgia Y Y BCBS-North Carolina Y Y BCBS-South Carolina Y Y BCBS-Tennessee Y Y Capitol Life N N Care Improvement Plus Y N Celtic N N Central United Life Insurance Company Y Y Christian Fidelity N Y Cigna- HealthSpring (HealthSpring) Y N Cigna- Supplemental Benefits Y Y Colorado Bankers Life N N Combined Insurance Company of America Y Y Consumers Choice Health Plan Y Y Continental Life N N Coventry Advantra Freedom N N Coventry Health Care of Carolinas Y Y Coventry One- Georgia N N EquiTrust- Annuity Y N Fidelity Life Y Y

5 Carrier Selection: Please select which carriers below you d like to be appointed with through Messer Financial Group Carrier Name E&O Required Direct Deposit Required Foresters Y Y Forethought- Life Y Y Genworth Life- Fixed Life & Annuity Y N Gerber Life- Medicare Supplement Y Y Great American Y N Guggenheim Life & Annuity Company Y Y Heartland National Life Y N Humana- Medicare N N HumanaOne Y Y IHC Health Solutions Y Y ING USA- Annuities Y N Liberty Bankers Life N N Life of the Southwest Y N Lincoln Financial Y N Loyal American Y N Manhattan Life N Y Mass Mutual Life & Annuity Y N MedAmerica Y N Mutual of Omaha Insurance Company Y N National Slovak Society Y Y National Stop Gap (NSG) Y N National Western- Annuity Y N Nationwide Y N New Era (Philadelphia American) Y Y North American Company (NACOLAH)- Y N North American Company (NACOLAH)- Life Y N Optum Health N N Oxford Life N Y Phoenix Y N Piedmont WellStar HealthPlans Y Y Premier Health Plan Inc. Y Y Protective Life- Annuity Y N

6 Carrier Selection: Please select which carriers below you d like to be appointed with through Messer Financial Group Carrier Name E&O Required Direct Deposit Required Pudential Financial Y N Pyramid N N Savings Bank Life of MA Y Y Security Life- Dental Y Y Sentinel Security Life Insurance Y Y Company Settlers Life N Y Trans-Family Markets N N United Commercial Travelers Y N United Health Care- Medicare Y N United Health One, Golden Rule Insurance Y N Wellcard N N WellCare N N Windsor Health Plan N N

7 General Questions- All questions below must be completed, regardless of carriers chosen 1. Do you currently have Errors and Omissions coverage? 2. What is the name of your Errors and Omissions Carrier? 3. What is your Errors and Omissions policy number? 4. What is the dollar amount of your Errors and Omissions coverage? Enter the amounts using numbers only. $ 5. Per claim amount $ Aggregate claim amount $ 6. Error and Omissions effective date 7. Errors and Omissions expiration date 8. What type of contract are you requesting? (CIRCLE ONE) Individual (the commissions being paid to you are reported to the IRS with your SSN) Agency (the commissions being paid to you, as a signing Officer, are reported to the IRS with your Business Name and Federal Employer Identification Number) License (the commissions you earn are being paid to another person or entity) 9. Are you a citizen of the United States of America? 10. If you are NOT a U.S. citizen, please give details of how you are approved to work in the U.S. such as: a resident alien number or a visa number, the terms of your stay, and any other relevant information. 11. If you have a webpage you would like carriers to know about, please enter it here. www. 12. Driver s license issuing state Driver s license # Expiration Date

8 General Questions- All questions below must be completed, regardless of carriers chosen 13. Are you currently licensed in your resident state? 14. Are you currently licensed and requesting contracting in any non-resident state? (Hint: do not select yes if you do not wish to get contracted in any non-resident state) 15. Are you currently FINRA (formerly NASD) registered? Hint: If your FINRA license is INACTIVE please answer No to this question. If you answer Yes you will be REQUIRED to provide your FINRA license information. License Information: 16. Have you ever had a claim filed against your Professional Liability or Errors and Omissions insurance coverage or has any E&O Carrier denied, paid claims on, or canceled your coverage? 17. Are you now or have you ever been employed by, or associated with to any degree, directly or indirectly, a bank, savings and loan or other financial institution? 18. Please indicate the size of customer that you typically represent: -Medicareeligible individuals and/or individuals age 65 and over? (CIRCLE ONE) eligible employee s -51-3,000 eligible employees -3,000+ eligible employees 19. Line of business: (CIRCLE ONE) -Individual Small Group Retiree Markets Middle Market National Accounts By signing, I state that I am the person or authorized representative of the entity applying for Representative Contract, and that I have read, understand and agree to the terms and conditions specified in the Representative Contract. Agent Signature Date

9 Carrier-Specific Questions- All questions below are carrier-specific, in alphabetical order. Please answer all questions associated with ONLY your selected carriers Aetna If you currently work with an Aetna sales representative, please indicate his/her name: American Equity 1. Important state and federal training requirements. You will need to be compliant with these regulations before American Equity will be able to accept and issue any business you submit. Company specific product training completed? Life Investors First years premium expectations with Life Investors? $ Complete the last 3 years of agent recruiting and premium activity? Have you previously represented a member of the AEGON Group? If yes please enter company, agent ID, and dates of appointment FROM/TO American National If new business is being submitted with please provide the application date: Will you be selling the FEDD, 457 or other special markets? Military Status (if applicable) ACTIVE RETIRED N/A American National would like you to choose a password for online access. (Note: this password must be in all uppercase letters) PASSWORD: Americo Has new business been submitted? If so, enter application date and name of applicant below: Date and Name of First Policy App Submitted: Aviva Life and Annuity Company Have you ever applied for a contract with any of the AVIVA companies? If Yes, then list the AVIVA companies and agent codes:

10 Assurity Life Insurance Company Have you completed LTCI continuing education? How many years have you been licensed as an insurance agent? Banner Life How often would you like to be paid your commissions by Banner Life? Would you like to receive your commission reports from Banner Life by ? BCBS SC Please check here if you agree to the Production Requirement of 6 applications in 6 months: Please enter the number of new business applications you are submitting (if applicable): (CIRCLE ALL THAT APPLY) What markets do you specialize in? Individual Health, senior market, small group health, life & annuities Are you currently on, or have you ever received financing, annualization, advance commissions or authority to deposit applicants' checks in your own account with any Company? If yes list what companies. Please indicate the number of contracts (lives) you anticipate writing each year: Capitol Life For all business, I elect to have my commission paid under: (CIRCLE ONE) First year commission with annual trails, if I qualify higher first year commission with no trails. Celtic Insurance Company Have you submitted a New Business case along with this appointment application? Do you understand that you are not to use the appointment applied for principally to produce Insurance coverage for personal use, for relatives, or for a firm or corporation in which you own an interest? Do you understand that willful misrepresentation of any fact required to be disclosed through this application is a violation of the insurance code and may result in the denial of your application and/or revocation of your insurance license(s)? Do you understand that you represent the interest of the Applicant for participation, not Celtic Insurance Company, and have advised your client not to terminate any existing coverage until receiving notice of coverage and that you have no right to bind coverage, to alter terms of the Insurance Contract or Application in any manner, or to adjust any claim for benefits under the Insurance Contract?

11 CIGNA Your Med Supp first year annualized issued premium for the past 12 months was: $ (For amounts of $500,000 or more submit proof of production with this application to your appointing agnecy contact point) Are you applying for an advance (Commission Payment) If yes, please check one: (CIRCLE ONE) 12 months, 9 months, 6 months, 15 months Colorado Bankers Life Do you currently receive advances or annualized commissions? If yes give the name of the carrier (s): Forethought I acknowledge that I must complete Annuity Product Training before soliciting an annuity application. Have you completed Anti-Money Laundering (AML) training online via LIMRA? Furthermore, I acknowledge that I understand the following: Indexing is a method and formula for calculating interest, and may include such concepts and terms as participation rate, index cap, index spread, monthly averaging, point-to-point, and index averaging period. The Forethought Destination Indexed Annuity is not a registered security or stock market investment and does not directly participate in any stock or equity investment. While the interest credited to these annuities is calculated by a formula linked in part to the Standard & Poor s 500 Index, the annuity performance will not match the performance of that Index. The actual interest credited may be zero percent, although there are minimum guaranteed values, which may be subject to withdrawal charges and interest adjustments. The final decision regarding the premium allocation between the fixed account strategy and indexed account strategies of an annuity product is the annuity owner s, based on their individual situation, needs and goals, and that I may not act as a registered investment adviser. No representation, prediction, or guarantee of future interest performance may be made at any time, and past performance is never an indication of future performance. The products are intended for retirement funding or other long-term accumulation needs with substantial contract-imposed penalties. As such, they may not be appropriate for all consumers. I will provide a copy of the Disclosure Statement and Buyer s Guide to all annuity applicants. Foresters Has new business been submitted to Foresters for processing? United HealthOne, Golden Rule Do you have clients in the 50+ Market? How many? Do you offer life insurance to your clients? Do you write single premium, asset based products? If yes approximately how much do you write in annuity premium annually? What type of annuity do you offer? (CIRCLE ALL THAT APPLY) Fixed, variable, immediate Who is your primary annuity company?

12 Who is your primary life company? Who is your primary long-term care company? How interested are you in long term care planning? (CIRCLE ONE) Very, interested, not interested Approximately how many long-term care cases do you sell annually? How many new permanent individual health applications did you personally write in the past 12 months with all companies combined -- excluding Short Term, Medigap, and Employer/Group policies? How many do you plan to write in the next year? What type of permanent individual health plans do you personally write most often -- excluding Short Term, Medigap, and Employer/Group policies? IN the past 12 months, how many of the following products have you written? Medicare supplements, short term medical plans, employee small group health. How many new permanent individual health applications did you personally write in the past 12 months with all companies combined -- excluding Short Term, Medigap, and Employer/Group policies? Loyal American Do you want to receive commissions deposits and sign up for Garfri's secured agents websites? Commission Payment Frequency: (CIRCLE METHOD) Daily, Weekly, BiWeekly, Monthly For Loyal American, what would be your primary market? Are you requesting the receipt of commission on an advance basis? Heartland National Life Which products are you interested in selling? (CIRCLE ALL THAT APPLY) Cancer Plan, Cash Supplement, Medicare Supplement How did you hear about Heartland? Which states would you like to be appointed in? Life of the Southwest How did you hear about LSW? Do you currently sell in the Hispanic Market? Percentage of business done in the Hispanic market? Amount of sales done in the Hispanic Market? Do you currently sell retirement planning products? Percentage of sales done in retirement planning products? Amount of sales done in retirement planning products?

13 Lincoln Financial Group May we publish your name in company publications? If no, is recognition (awards, conference) acceptable? Projected annualized paid life and annuity premium(s) during my first 12 months with Lincoln will be at least: Life/Annuity $ Mass Mutual Life and Annuity Please indicate the line(s) of business you are requesting appointments for: (CIRCLE ONE) annuity, life, annuity & life DO you engage in any business other than insurance? If yes please describe including amount of time spent: Are you a trustee, manager, director, officer of otherwise in charge, in whole or in part, of any property or interests of others who carry insurance? Are you currently selling insurance over the Internet? Have you done business with another Mass Mutual General Agent in the last 24 months? If yes, explain: Med America Have you solicited an application on MedAmerica s Behalf? If yes, please provide application signature date: National Western Life Do you authorize NWL to provide your name and contact information to other NWL agents, customers, and/or potential NWL customers seeking an NWL agent in their area? What is your preferred earned commission frequency from National Western? Is new business being submitted to National western life with this contract? If so what date was the app written, what name should agent contract be issued? What are your primary markets? Nationwide Do you want publicity? Annualized Special Risks Health (SRH) premium you currently have in force with all insurers?$ Annualized SRH premium you anticipate having in force with all insurers within one year? $ Does your firm prefer Life Contracts delivered to another recipient other than the Owner?

14 Is your agency a wholesaler? If yes how many names are on its mailing list(s) How many care considered active producers for the Agency? Does your firm prefer Life Contracts delivered to another recipient other than the Owner? If yes supply address: North American Company for Life and Health Insurance Please list all relatives who are currently licensed to sell life insurance Name relationship and SSN: What types of products do you plan to sell for North American Company? (CIRCLE ONE) Life or Annuity Mutual of Omaha Identify the state(s) the contracted individual/entity is to be appointed to represent Mutual of Omaha Insurance Company. Identify the state(s) the contracted individual/entity is to be appointed to represent United of Omaha Life Insurance Company. Identify the state(s) the contracted individual/entity is to be appointed to represent United World Life Insurance Company. What type of product(s) do you plan to sell for Mutual of Omaha Insurance Company (United of Omaha Life Ins. Co., United World Life Ins. Co.)? (CIRCLE ALL THAT APPLY) Life, annuity, mutual of Omaha long term care, united of Omaha long term care, medsups, termlife express, critical illness and disability. Selection of advanced commission options: Oxford Life How much premium do you expect to produce for Oxford Life during the first year? $ Are you interested in purchasing E&O coverage sponsored by Oxford Life? Phoenix Life Advance Commission The Producer and Distributor must select one of the options below: (CIRCLE ONE)-do not advance commissions to the Producer begin advancing commission to the producer If advancing commission to the Producer is chosen, please select the amount of the annualization payment: (CIRCLE ONE) 3, 6, or 9 months Prudential Lines of business requested: (CIRCLE ALL THAT APPLY) life, variable, long term care

15 Reason for appointment: sales/service, if service please include annuity contract number. Please select what product line you wish to sell or service: (CIRCLE ALL THAT APPLY) American Skandia variable, prudential variable, prudential fixed Submission of new life business? If yes include name of insured: Do you know your rep code provided by your broker dealer? What is your rep code? Pyramid Is your Drivers License currently suspended or revoked? Do you maintain auto-insurance coverage that satisfies the minimum requirements for your state? Savings Bank Life of MA Would you like for your brokers to view their business online? Are you submitting an application for Insurance with this application for appointment? If yes what is the date the application for insurance was signed? What is your current status? (CIRCLE ONE) Owner/partner, corporate officer, representative (agent) Settlers Life Who do you want Settlers Life to mail issued policies to? How often do you wish to be paid your commissions? (Make sure this answer matches the Banking Authorization) Can Settlers Life publish your photo and/or records of sales and accomplishments on our website ( and in our company newsletters? Photos on website, photos in newsletter, records on website, records in newsletter Settlers Life would like to rely upon the investigative reports obtained by NGL as part of your appointment and contracting process with it. This should help speed up your appointment with Settlers Life. Do you grant National Guardian Life Insurance Company the authority to share any such investigative reports with Settlers Life? United Commercial Travelers Production Record Personal-Prior Calender year (life premium, life volume, health premium, group premium) Agency-prior calendar year (life premium, life volume, health premium, group premium)

16 Personal-current year to date (life premium, life volume, health premium, group premium) Agency current year to date (life premium, life volume, health premium, group premium) Personal 13 month persistency (life premium, life volume, health premium, group premium) Agency 13 month persistency (life premium, life volume, health premium, group premium) Total number of producing agents or brokers in your agency? How many will be appointed with UCT? Following questions are required for the application for membership and accident coverage: Member number (if you are currently a member) Height/Weight: / Kind of Business: (CIRCLE ALL THAT APPLY) wholesale, retail, manufacturing, other Other business? Occupation title or position: State fully your occupational duties: United Healthcare If you wish to be appointed to represent a Local UHG Health Plan, if yes what plan: Are you an employee of a UHG sales office? Have you had your driver s license revoked within the past three years? Windsor Health Plan Do you have previous Medicare Advantage sales experience? How many applications did you process last year? General Agent? Are you a Managing

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18 Form W-9 (Rev. August 2013) Department of the Treasury Internal Revenue Service Name (as shown on your income tax return) Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. Business name/disregarded entity name, if different from above Check appropriate box for federal tax classification: Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Other (see instructions) Address (number, street, and apt. or suite no.) City, state, and ZIP code Exemptions (see instructions): Exempt payee code (if any) Exemption from FATCA reporting code (if any) Requester s name and address (optional) List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the Name line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Social security number Employer identification number Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person (defined below), and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3. Sign Here Signature of U.S. person Date General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. The IRS has created a page on IRS.gov for information about Form W-9, at Information about any future developments affecting Form W-9 (such as legislation enacted after we release it) will be posted on that page. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, payments made to you in settlement of payment card and third party network transactions, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners share of effectively connected income, and 4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. Note. If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester s form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: An individual who is a U.S. citizen or U.S. resident alien, A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, An estate (other than a foreign estate), or A domestic trust (as defined in Regulations section ). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.

19 Authorization Agreement for Automatic Deposit I (We) herby authorize Messer Financial to initiate Automated Clearing House credits. AGENT INFORMATION Agent or Agency Name: Social Security number/tax ID number: Phone Number: Please indicate transaction type: Set-up Change Cancel Please indicate type of account: Checking Savings FINANCIAL INFORMATION Bank Name: Bank Address: City: State: Zip: Bank phone number: Bank account number: Bank routing number: (Please provide the nine-digit routing number on your check, not the deposit slip) This authorization will remain in force until written notification of termination or change is received by Messer Financial in such time and in such manner as to afford Messer Financial opportunity to act on it. NOTE: Direct deposit set-up requires that the bank account and routing number must be verified for accuracy before any funds are transferred. For this reason, you may receive one or two commission checks that need to be cashed. Print Name: Signature: Date: PLEASE INCLUDE A COPY OF A VOIDED CHECK

20 . 11/1/2009 Gary Tim Ferguson 5208 Crooked Bluff Lane Fuquay Varina, NC Please Attach Voided Check To This Sheet /1/ /1/2010 VOID

21 ATTENTION!!! DO NOT SUBMIT WITHOUT ALL ITEMS BELOW! Items in bold will cause your contract to be held if not included with your contract- PLEASE INCLUDE ALL DOCUMENTS REQUESTED General Agent Agreement o Signature Page o Current E&O Declarations Page o Current State License for selected carriers o Agent Information Completed Entirely o Tax Identification W9 Completed o SSN, NPN, & Hierarchy Completed Background & Information Sheet o Any questions answered YES requires a written, signed, and dated explanation Commissions Deposit Authorization o Direct Deposit Form Completed o Voided Check for account to be paid- Agent or Agency FAX TO: