LIFE AND P&C AGENCY COST AND OPTIONS

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Philippa Hodge
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LIFE AND P&C AGENCY COST AND OPTIONS INSTRUCTIONS PLEASE READ BEFORE PROCEEDING - If the Life Agency s total Commission and fee income is greater than the P&C Agency s total commission and fee

coverage Options I6-II6 options A-F (Next page) AGENCY INFORMATION Entity Name: Effective Date: Total Life Premium: $ Total P&C Premium: $ Total Employed Agents: Total Ind. Contractors: 1.

If this applies to your agency please provide the following to receive a customized pricing: Total Agency Commission/Fee Income: $ Option(s) Needed: Limit(s) Requested: COVERAGE OPTIONS I5 II5 For

Fee Income of $0-$250,000 1 Limits $1M/$1M $1M/$2M $1M/$3M $2M/$3M Limits $1M/$1M $1M/$2M $1M/$3M $2M/$3M Retention 2 $1,000/$5,000 $1,000/$5,000 $1,000/$5,000 $1,000/$5,000 Retention 2 $1,000/$5,000

1 LIFE AND P&C AGENCY COST AND OPTIONS INSTRUCTIONS PLEASE READ BEFORE PROCEEDING - If the Life Agency s total Commission and fee income is greater than the P&C Agency s total commission and fee income, chose from coverage Options I5-II5 options A-F (This page) - If the P&C Agency s total commission and fee income is greater than the Life Agency s total commission and fee income, chose from coverage Options I6-II6 options A-F (Next page) AGENCY INFORMATION Entity Name: Effective Date: Total Life Premium: $ Total P&C Premium: $ Total Employed Agents: Total Ind. Contractors: 1. Agencies earning $500,001 or more must complete this application and have customized pricing to be insured under this master policy. If this applies to your agency please provide the following to receive a customized pricing: Total Agency Commission/Fee Income: $ Option(s) Needed: Limit(s) Requested: COVERAGE OPTIONS I5 II5 For Agency named insured with a majority of Total commission and Fee Income from Life Insurance Agent, Annuity and Registered Representative Activities I5 - Agency Named Insured with Total Commission and Fee Income of $0-$250,000 1 Limits $1M/$1M $1M/$2M $1M/$3M $2M/$3M Limits $1M/$1M $1M/$2M $1M/$3M $2M/$3M Retention 2 $1,000/$5,000 $1,000/$5,000 $1,000/$5,000 $1,000/$5,000 Retention 2 $1,000/$5,000 $1,000/$5,000 $1,000/$5,000 $1,000/$5,000 $825 $875 $925 $1,450 Option C $1,125 $1,250 $1,350 $2,000 Option A Option B PLUS Life, Health, Variable Products and Mutual Funds Option B Option A PLUS $925 $1,025 $1,075 $1,650 Option D Option C PLUS $1,550 $1,750 $1,950 $3,225 Surcharge to Add P&C Coverage Options Add Coverage Option A, B, C or D to E or F $750 $850 $1,045 $1,050 $1,250 $1,600 Option E Personal Lines II5 - Agency Named Insured with Total Commission and Fee Income of $250,001 - $500,000 1 Limits $1M/$1M $1M/$2M $1M/$3M $2M/$3M Limits $1M/$1M $1M/$2M $1M/$3M $2M/$3M Retention 2 $1,000/$5,000 $1,000/$5,000 $1,000/$5,000 $1,000/$5,000 Retention 2 $1,000/$5,000 $1,000/$5,000 $1,000/$5,000 $1,000/$5,000 $1,375 $1,475 $1,575 $2,650 Option C $1,975 $2,275 $2,425 $3,650 Option A Option B PLUS Life, Health, Variable Products and Mutual Funds Option B Option A PLUS $1,600 $1,825 $1,900 $3,050 Option D Option C PLUS Total for Section I5: $ $2,850 $3,350 $3,550 $5,350 Surcharge to Add P&C Coverage Options Add Coverage Option A, B, C or D to E or F $1,225 $1,450 $1,945 $1,825 $2,275 $3,150 Option E Personal Lines Total for Section II5: $ 2. The $1,000 retention applies to claims involving Fixed Products only and the $5,000 retention applies to claims involving variable products. 3. The $5,000 retention applies to claims that only involve personal lines, and the $10,000 applies in all other cases, i.e. claims involving commercial lines. V4 May of 5

2 COVERAGE OPTIONS I6 II6 For Agency named insured with a majority of Total commission and Fee Income from P&C Insurance Agent Activities I6 Agency Named Insured with Total Commission and Fee Income of $0-$250,000 1 $1,075 $1,200 $1,550 $1,300 $1,450 $1,950 Option E Personal Lines Surcharge to Add Life/Annuity/ Series 6&7 Add Coverage Option E or F to A, B, C or D Retention 2 $1,000/$5,000 $1,000/$5,000 $1,000/$5,000 Retention 2 $1,000/$5,000 $1,000/$5,000 $1,000/$5,000 Option A Life, Health, $700 $775 $875 Option C Option B PLUS Variable Products and Mutual Funds $925 $1,050 $1,225 Option B- Option A PLUS $825 $925 $1,025 Option D Option C PLUS $1,300 $1,450 $1,750 Total for Section I6: $ II6 Agency Named Insured with Total Commission and Fee Income of $250,001 - $500,000 1 $1,900 $2,125 $2,925 $2,350 $2,650 $3,750 Option E Personal Lines Surcharge to Add Life/Annuity/ Series 6&7 Add Coverage Option E or F to A, B, C or D Retention 2 $1,000/$5,000 $1,000/$5,000 $1,000/$5,000 Retention 2 $1,000/$5,000 $1,000/$5,000 $1,000/$5,000 Option A Life, Health, $1,150 $1,300 $1,500 Option C Option B PLUS Variable Products and Mutual Funds $1,600 $1,825 $2,225 Option B- Option A PLUS $1,375 $1,600 $1,800 Option D Option C PLUS $2,350 $2,650 $3,250 Total for Section II6: $ tes/comments: V4 May of 5

Entity Applicant Name: Applicant must be able to truthfully answer yes to question 1 and no to questions 2 through 10 posed below in order to qualify for insurance coverage under this Program.

3 Entity Applicant Name: Applicant must be able to truthfully answer yes to question 1 and no to questions 2 through 10 posed below in order to qualify for insurance coverage under this Program. If Applicant fails to answer any question, or if Applicant answers no to question 1 or yes to any of the questions 2-10, Applicant will not qualify for coverage under this Program without additional underwriting review and approval. Applicant can be an Investment Advisory Firm (which would include all of its employees and its exclusive IAR s as insureds) or an insurance agency and its employed and independent contractor named insured agents, acting as a life insurance agent and/or property and casualty insurance agent and/or Series 6 on 7 registered representative as set forth for that named insured on the Named Insureds Endorsement; provided, coverage for an employee or independent contractor of a named insured agency only applies with respect to covered activities carried out by, or through, or with the written approval of that named insured agency. The primary contact of the Agency makes all representations, warranties and agreements on behalf of Applicant including its officers, directors, partners, employees and independent contractors for whom insurance is sought under this Application. 2. Has any complaint, claim, suit or arbitration for alleged malpractice, error, omission, mistake or other wrongful acts been made against Applicant in the last 10 years? 3. If Applicant is or was a Registered Representative, are there or were there any yes answers on Applicant s U-4 arising from issues in the last 10 years, or have any complaints been expunged in the last 10 years? 4. After a review of Applicant s records, does Applicant have any knowledge or information of any fact, situation, allegation or incident which may result in a complaint, claim, suit or arbitration against Applicant? 5. Is Applicant aware of or involved in any fee or other type of dispute with a client? 6. Has any professional license or registration of Applicant been denied, suspended, revoked, nonrenewed or restricted in any way in the last 10 years? 7. Has Applicant been the subject of any investigation, inquiry or complaint by any state or federal regulatory agency, consumer agency, or any other agency (including, but not limited to, the SEC, FINRA, and state securities, corporation or insurance department) that resulted in a regulatory enforcement or consent order, cease and desist order or other enforcement order, disciplinary action, sanction, censure, reprimand, fine, or suspension or in a formal reprimand by any court in the last 10 years, or is Applicant currently under investigation by any of these authorities? 8. Has Applicant be convicted of any felony, or of any business related misdemeanor, or is Applicant currently under investigation or indictment, or otherwise named as a defendant, respondent, or party to any criminal proceeding other than traffic violations, in the last 10 years? 9. Has any contract between Applicant and his/her insurance company, broker/dealer, registered investment advisor, or others been suspended, restricted, terminated or non-renewed for cause in the last 10 years? 10. Has Applicant had his/her professional liability insurance policy or fidelity bond declined, canceled, issued on special terms, renewal refused or had a request that his/her application for insurance or for a bond be withdrawn in the last 10 years? V4 May of 5

4 AUTO-RENEWAL INFORMATION Reminder: As soon as an insured knows of an alleged "wrongful act" which may result in a covered "written claim", the insured must give the insurer written notice of the details. All such notices are to be by a separate document and not part of the renewal application. See the policy for all claim reporting obligations and information. ACCEPTANCE 1. I accept the representations, warranties and agreements. 2. I understand that coverage applies only for the products and services listed in the coverage option I have selected. 3. I understand that Prior Acts coverage is available under the policy and applies only for products listed in the coverage option I have selected and that not all options/features cover prior acts. 4. By enrolling in the Defender Max Program, I hereby provide InterWeb Insurance with the credit card authorization and the right to automatically charge the renewal cost to the card in future years. 5. By applying for this insurance, I am applying for membership in the Interweb Purchasing Group, a group formed and operating pursuant to the Liability Risk Retention Act of 1986(15 USC 3901et seq.). Applicant Signature: Date: Please submit completed enrollment material to Michelle@InterWebInsurance.com or Fax: (888) V4 May of 5

5 LIFE AND/OR P&C AGENCY CONTACT INFORMATION AND PAYMENT FORM INTRODUCTION Referred By: 1. tice: Defender Max is an affordable, "Instant Access" program with a menu of coverage options at set pricing. It is designed to meet the needs of the majority of applicants. If your firm/agency does not meet the eligibility requirements, have revenue greater than the thresholds or have broader coverage needs, please contact Customer Service. We can submit your application manually to the underwriter for special consideration so you can take advantage of the great benefits of the program. 2. Payment Options: Pay in full by credit card or check, or monthly payments via premium financing with a down payment (check or credit card) and 9 monthly payments. Payments will be the responsibility of the Contact Name on the CIPF. Failure to make the payment(s) will result in loss of coverage for all individuals. 3. Applicants: Applicant can be an investment advisory firm or a Life and/or P&C agency (which would include all of its employees, agents and its exclusive IAR s as insureds) 4. The primary contact noted below makes all representations, warranties and agreements on behalf of Applicant including its officers, directors, partners, employees and independent contractors for whom insurance is sought under this Application. All certificates of insurance will be ed to the primary contact. APPLICANT Entity Name: Address: Office Phone: Contact Name: Contact PRODUCT AND ACTIVITY Percentage Break Down by Product Fixed Life, Health, % Variable Products % Fixed Annuity % Mutual Funds % % Other Securities % LP, REIT, Private Placements % Hedge Funds % Other Insurance % PAYMENT METHOD Credit Card Pay in Full Prem. Financing Check Pay in Full Prem. Financing Card. Questions? Call Customer Service at (866) Expiration Date: Where to send? Please make check payable to InterWeb Insurance Security Code: Billing Zip Code: Mail 3269 Maricopa Ave. Ste Lake Havasu City, AZ Cardholder s Name: Michelle@InterWebInsurance.com Today s Date: Fax (888) Please indicate credit card being used Offered By: InterWeb Insurance LLC. License MasterCard Visa Discover AMEX Premium Financing Down Payment Amount: $ The down payment will be 25% of the total premium and fees. You will pay this by Credit Card or Check. If paying by Credit Card please provide credit card information above. A premium finance contract will be ed to you along with a receipt for the down payment. The finance contract will contain the APR and finance charge. We will assume you agree with those terms and sign and execute the contract on your behalf if you do not advise within 24 hours. The finance company will invoice you monthly for 9 months. By signing below, you agree to this process. AUTHORIZATION I,, authorize InterWeb Insurance to charge my credit card account on / / for the amount of $, from the credit card information listed above. This payment authorization is valid and to remain in full force and effect unless I notify InterWeb Insurance of its cancellation by sending written notice to: InterWeb Insurance 3269 Maricopa Ave. Ste or by ing: Michelle@InterWebInsurance.com Please note: There is a minimum earned premium of 25%. Broker administration fees are not refundable. Date: Cardholder Signature: Print Name: V4 May of 5

INVESTMENT ADVISORY FIRM COST AND OPTIONS

INVESTMENT ADVISORY FIRM COST AND OPTIONS Options 4G and 4H COST PER FIRM WITH TWO OR MORE PROFESSIONALS (including independent contractor IAR s) 1 Option 4G Asset Allocation- n- Discretionary 2 Assets