Agent Level 4 Medstar Medicare Choice Health Contracting Checklist:

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1 Agent Level 4 Medstar Medicare Choice Health Contracting Checklist: Please complete and return ALL of the attached contracting for Medstar Medicare Choice: Contracting Packet Completed: Complete and sign pages 2, 3, 6, 7, AND 9 and return contracting packet including: Attachment C Code of Conduct Acknowledgment Form Attachment D Brand/Marketing Acknowledgment Form Electronic Payment (ACH) Authorization plus a copy voided check for direct deposit (EFT Only) W-9 Form Assignment of Commissions form - complete if you will be assigning your commissions to your agency Copy of current E&O policy/coverage Copy of valid DC and MD State licenses Copy of 2016 AHIP ***A face-to-face meeting and agent certification test is required. Arrangements will be made through Insurance Company for the meeting and test after initial review of contracting. Please completed paperwork to: brad@securebenefitsalliance.com or Fax to: If you have any questions, please call and ask for contracting department. Thank you. 1

2 evolent HEALTH Vr ATTACHMENT E MEDICARE ADVANTAGE BROKER APPOINTMENT/RECERTIFICATION APPLICATION SECTION 1: FORM PURPOSE Initial Appointment Annual Recertification MedStar Piedmont WellStar HealthPlans Premier Health Plan SECTION 2: BROKER INFORMATION First Name M.I. Last Name Social Security # Date of Birth (MM/DD/YYYY) National Producer # (NPN) Business Phone Number Ext. Address Fax Number Mobile Number Mailing Address City State ZIP Code Physical Address (if different) City State ZIP Code Doing Business as: Individual Business Entity Agent Assigns Commissions To Agency Agent Paid Direct SECTION 3: FMO/AGENCY AFFILIATION FMO: Business Name Business Tax ID Business Address City/State Zip Code General Agent / Up line (if applicable): Gateway Strategies _ SECTION 4: E & O POLICY INFORMATION - Please include a copy of your declaration page or certification with application. Policy Amount Policy # Policy Carrier Effective Date Expiration Date SECTION 5: LICENSING QUESTIONS 1. Has your insurance license ever been suspended or revoked by any insurance regulatory body? Yes No 2. Have you ever been named as a party to a lawsuit involving a policy of insurance you sold, or has any company you sold for been named in a lawsuit as a result of a policy you sold? Yes No 3. By signing below, you acknowledge that you are applying for appointment to sell Medicare Advantage product(s) through the above named FMO and that that you are obligated to follow Evolent Health's in-force FMO release policy should you decide to transfer to another FMO in the future. 4. By signing below, you acknowledge that you may not market, solicit or sell Medicare Advantage plan(s) until you have been appointed to do so and until you have been provided an Agent Writing Number (AWN) by Evolent as confirmation of such appointment. Further, you attest that you will only engage prospective Beneficiaries in accordance with annual enrollment guidelines established by CMS and only for enrollment periods and products for which you have been certified and provided an AWN. I hereby certify that I am acting on my own behalf and that the foregoing statements are true and correct to the best of my knowledge and belief. Broker Signature: Date (MM/DD/YYYY) X 2

3 MEDICARE PRODUCTS GENERAL AGENT AGREEMENT The Agreement is made as of, 2015 by and between Gateway Strategies, LLC. ( Agency ) with offices at 300 Bilmar Drive. Suite 200. Pittsburgh, PA and at.( Agent ). WHEREAS, Agency is providing managed services for various Medicare Advantage products (the "Products") of Medstar Medicare Choice ( Sponsoring Company ) to Agent ; WHEREAS, Agent will gain appointment to market and solicit Medicare advantage products on behalf of Medstar Medicare Choice and is licensed under the insurance laws of the soliciting state as required to perform under this Agreement. NOW, THEREFORE, in consideration of the covenants and mutual promises set forth herein, and intending to be legally bound hereby, both parties agree as follows: a. Duties of Agent. The Agency hereby appoints Agent to solicit applications for Medstar Medicare Choice (hereinafter, the Sponsoring Company ) and to service the insurance agreements procured by the Agent. b. Relationship of the Parties. a. The parties expressly agree that Agent will be an independent contractor of the Agency and that nothing in the Agreement will be construed to create an employer/employee relationship between the parties and that Agent shall not hold himself/herself out in any capacity other than as an independent agent of Agency. b. Agent specifically agrees that he/she will be responsible for all payments required to be made under the Federal Insurance contributions Act (FICA), the Social Security Act, the Federal or State Unemployment Tax Act, Income Tax Withholding, and/or Workmen s Compensation. c. Agent shall be free to exercise his/her own independent judgment as to the time, place and manner in which he/she performs the services provided for by this Agreement except that Agent, in the performance of such duties, shall not breach and local, state or federal regulation or conduct business which in anyway would be unethical as set forth by the insurance industry or impair the good will or reputation of the Agency. d. Agent shall be responsible for and pay any and all expenses incurred in conducting business under the terms of this Agreement, including the procurement and payment of all licenses and errors & omissions insurance. Agent is not eligible to participate in any fringe benefit programs sponsored by the Agency for employees. 3

4 c. Limitations on Agent s Authority. a. Represent himself/herself as an employee, partner, joint venture or associate of the Agency or as an agent of the Agency or of the Sponsoring Company for any purpose other than that specified herein. b. Modify or waive, in any respect, any of the terms, provisions, limitations, conditions or premium rates regarding any applications, policies, receipts, announcements, or promotional or instructional materials. c. Utilize any Advertisement regarding the Sponsoring Company or their products without obtaining prior approval. For the purpose of this Agreement, the term Advertisement means any printed or published or audio visual material or sales talks utilized in direct mail, newspaper, radio or televisions scripts, billboards, websites, or similar displays where such Advertisement utilizes the Sponsoring Companies names or logos or refers to any of their products. d. Retain any portion of a collected premium as commission; or e. Bind the Sponsoring Company to any coverage or risk. No coverage will be effective with respect to any application until approved. The Agency and the Sponsoring Company reserve the right, based on their sole discretion and without liability to the Agent, to approve or disapprove any application. d. Compensation. a. Agent s sole compensation for the services provided in this Agreement shall be in the form of First Year Commissions, Renewal Commissions, and Service fees as described in the Commission Agreement attached. The Agency may amend the Commission Schedule at its sole discretion, as it pertains to Service Fees. e. Termination of Insurance or Denial of Application. a. The Agent shall not be entitled to any commissions upon any application declined or rejected by the Agency or the Sponsoring Company; or upon any unearned portion of any policy canceled by or at the request of the insured. f. Termination of Agreement a. Either party may terminate this Agreement, with our without cause, by providing two weeks notice to the other party by certified mail. b. This Agreement shall terminate immediately upon any of the following: i. Cancellation or revocation of the Agent s license to sell or solicit insurance by the state they conduct business in; ii. The Agent s death or total disability, whether mentally or physically caused; iii. The Agent s failure to pay over on demand any money due to or belonging to the Agency; iv. A determination by the Agency that the Agent has committed fraud, misappropriated or withheld funds, failed to property remit funds or deliver policies, or violated any criminal or insurance laws, or interfered with the Agency s business, or, v. Violation or breach of any provision of this Agreement by the Agent. g. Effect of Termination. a. Upon termination of this Agreement for any reason, Agent shall return or destroy all PHI received from, or created, received, maintained, or transmitted by Agent on behalf of, Sponsoring Company that Agent still maintains in any form. h. Release. a. In the event the Agent desires to transfer from Agency to another brokerage agency that sells Sponsoring Company products, a request for release must be delivered by certified mail to the Agency address herein. The Agency will have sole discretion to the approval of such release. If a release is not granted, Agent understands and agrees that it can still transfer to another brokerage agency that sells Sponsoring Company products, however, it shall not be permitted to sell Sponsoring Company products for the first ninety (90) days as a subagent for the new brokerage agency; the 90 days shall start at the time of notification of request for release to the Agency and Broker Manager. GATEWAY STRATEGIES, LLC. AGENT CONTRACT PAGE 4

5 i. Indemnification. i. The Agent agrees to defend, indemnify and hold harmless the Agency against any and all claims (including, but not limited to, reasonable attorney fees incident thereto) which arise out of Agent s actions pursuant to this Agreement, including claims arising out of the Agency s own negligence, unless a judicial determination is made that the claim results solely from the negligence of the Agency. The Agency, reserves the right, at its sole option, to defend any claim and expend such sums as may be necessary, including attorney s fees, and Agent shall immediately reimburse Agency for any such sums. j. Liability Insurance. a. Agent agrees that he/she shall carry Errors and Omissions liability insurance covering the Agent and the Agency in an amount not less than $1,000,000 per occurrence while this Agreement is in affect. Agent shall provide written proof of such insurance to Agency upon request. k. Severability. a. Each provision and sub-provision of the Agreement shall be interpreted in such manner as to be effective and valid under applicable law, but if any provision of the Agreement shall be adjudged to be invalid under applicable law, the remainder of the Agreement shall continue in full force and effect. Should a court of competent jurisdiction declare any of the provisions of the Agreement unenforceable, the parties agree that the court may revise or reconstruct such unenforceable provisions to better effectuate the intent of the parties. l. Protected Health Information. a. Agent is contractually obligated to the Covered Entities(beneficiaries) to protect and secure any PHI that Agent receives from or on behalf of the Covered Entities in accordance with HIPAA, as defined herein. i. Agent intends to protect the privacy and provide for the security of PHI disclosed pursuant to this Agreement in compliance with the Health Insurance Portability and Accountability Act of 1996, Subtitle D of the Health Information Technology for Economic and Clinical Health Act of 2009 ("HITECH"), and regulations and other guidance promulgated under both laws by the U.S. Department of Health and Human Services (collectively, "HIPAA"), as well as other applicable federal and state laws. m. Disclosure for Administration/Legal Responsibilites. a. Disclose PHI, but only to the minimum extent necessary, for the proper management and administration of Agent or to carry out the legal responsibilities of Agent, provided that: i. The disclosures are Required by Law; or ii. Agent obtains reasonable assurances from the person, or other entity, including Agent, to whom the PHI is disclosed that it shall remain confidential and shall be used or further disclosed only as Required by Law or for the purpose for which it was disclosed to the agent, person, or other entity (which purpose must be consistent with the limitations imposed upon Agent pursuant to this Agreement), and that the agent, person, or other entity, agrees to promptly notify Agency of any instances of which it is aware in which the confidentiality of the information has been breached. GATEWAY STRATEGIES, LLC. AGENT CONTRACT PAGE 5

6 n. Reporting of Improper Use or Disclosure, Breach of Unsecured PHI, or Security Incident. a. Agent shall report within five (5) business days to Agency any use, access, acquisition or disclosure of PHI not provided for by this Agreement of which it becomes aware and (2) any Security Incident of which it becomes aware, including, with respect to (1) and (2), Breaches of PHI as required by 45 C.F.R With respect to (1), Agent shall report the use or disclosure even if it determines that the use or disclosure does not pose a significant risk of financial, reputational or other harm to the individual who is the subject of the PHI. All such reports shall be made to Agency without unreasonable delay after becoming aware of such issue(s), and in any event not to exceed five (5) business days following a Discovery of a Breach. In the case of a Breach, Agent shall provide Agency with the information required pursuant to 45 C.F.R (c) and shall reimburse Agency for all costs, expenses and damages (including reasonable attorney's fees) associated with any notification process required under HITECH or state breach notification laws. o. Notice. a. Any Notice required to be given under this Agreement shall be sent by certified U.S. mail, return receipt requested, addressed as follows: For the Agency: Gateway Strategies, LLC. 300 Bilmar Drive. Suite 200 Pittsburgh, PA p. Non-Waiver. a. Forbearance or neglect on the part of the Agency to insist upon compliance by the Agent with the terms and provision of the Agreement and rules and regulations of the Agency shall not be construed as or constitute a waiver thereof. Gateway Strategies, LLC. Agent: By: _ By: Name: Brian Breisinger Name: GATEWAY STRATEGIES, LLC. AGENT CONTRACT PAGE 6

7 COMPENSATION AGREEMENT LEVEL 4 (Agent) This agreement is for the payment of commissions for Medstar Medicare Choice, hereinafter referred to as the "Sponsoring Company". The agreement is between Gateway Strategies, LLC., hereinafter referred to as "GSNI" and hereinafter referred to as agent". 1. By accepting commission payments from "GSNI", "Agent" agrees to all of the "General Conditions" of this contract. If "Agent" is a corporation, the owners of the corporation agree to be personally, jointly and severally liable to this agreement. 2. Agent agrees to allow "GSNI" and Sponsoring Company to conduct monitoring activities including Ride Alongs and Secret Shopping activities. 3. "GSNI" shall pay commissions to "Agent" according to the terms of this agreement, however, nothing in this agreement shall be construed to violate the Marketing Guidelines of the Center for Medicare and Medicaid Services nor shall this agreement violate the terms and conditions of the Field Marketing Organization agreement between "GSNI" and the "Sponsoring Company". If there is any conflict between this agreement and the aforementioned, this agreement shall be amended to adhere to CMS regulations and to the "Field Marketing Company" agreement terms and conditions. 4. "GSNI" shall not be responsible to pay any commissions to "Agent" for any commissions where "GSNI" does not receive compensation from the "Sponsoring Company". 5. "Initial" First Year Commissions and "Replacement" First year commissions are determined by the "Insurance Company" in accordance with CMS Marketing Guidelines. "GSNI" will pay the "Initial" first year commission or "Replacement" first year commission in accordance with the "Insurance Company" payment. "GSNI" is not responsible for any dispute involving determining whether a first year commission is "Initial" or "Replacement". 6. "GSNI" will pay Commissions within seven (7) days of receipt of payment from Sponsoring Company. 7. The "Sponsoring Company" may charge back commissions to "GSNI" for a variety of reasons including but not limited to: Rapid Disenrollment of the member, Early Termination of the member, Corrections of Commissions paid to "GSNI" in error, etc. In cases where "Insurance Company" charges back commissions to "GSNI", "GSNI" will charge back all or a portion of commissions previously paid to "Agent". "Agent" agrees to promptly repay any debit balances which may accrue due to charge backs to the "Agent" account by "GSNI". If "Agent" does not promptly repay any "Debit" balances within sixty (60) days, "Agent" agrees to forfeit any future commission payments until Debit balance is cleared. 8. Agent acknowledges and agrees to cooperate with GNSI and Sponsoring Company on the submission of all licensure and background information in a timely and accurate manner. GATEWAY STRATEGIES, LLC. AGENT CONTRACT PAGE 7

8 9. Commissions are vested with the "Agent" subject to the following terms: a. "Agent" remains "in good standing" with "Sponsoring Company" according to CMS Marketing Guidelines and "Sponsoring Company" continues to pay commission to "GSNI" for "Agent" business. Good Standing means appointed to sell. b. "Agent" is not terminated for cause. Termination for cause includes violating the "Sponsoring Company" Code of Conduct, violating CMS Guidelines, violating state insurance law, violating the "Agent" contract with the "Sponsoring Company", bankruptcy or failure to maintain a valid insurance license. c. Agent remains current in GSNI hierarchy. 10. Definitions for Commission levels. Writing Agent levels are defined as Agent 4. For ALL Plans Initial (From Original Medicare or New to Medicare, determined by CMS). First payment will be made at the Replacement level until Sponsoring Company is notified by CMS to release the initial compensation and Sponsoring Company pays this to Gateway Strategies, LLC. D i s t r i c t O f C o l u m b i a Level Title 2016 MA/MAPD Year 1 Renewal Years 2+ 4 Agent 4 $ $ For Replacement Commissions excluding replacement of Sponsoring Company Individual Medicare Advantage (as defined by CMS) D i s t r i c t O f C o l u m b i a Level Title 2016 MA/MAPD Renewal Year 1 (Pro Rata Applies) Renewal Years 2+ 4 Agent 4 $ $ GATEWAY STRATEGIES, LLC. AGENT CONTRACT PAGE 8

9 For ALL Plans Initial (From Original Medicare or New to Medicare, determined by CMS). First payment will be made at the Replacement level until Sponsoring Company is notified by CMS to release the initial compensation and Sponsoring Company pays this to Gateway Strategies, LLC. M a r y l a n d Level Title 2016 MA/MAPD Year 1 Renewal Years 2+ 4 Agent 4 $ $ For Replacement Commissions excluding replacement of Sponsoring Company Individual Medicare Advantage (as defined by CMS) M a r y l a n d Level Title 2016 MA/MAPD Renewal Year 1 (Pro Rata Applies) Renewal Years 2+ 4 Agent 4 $ $ Gateway Strategies, LLC. Business Associate: By: _ By: Name: Brian Breisinger Name: GATEWAY STRATEGIES, LLC. AGENT CONTRACT PAGE 9

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14 Electronic Payment (ACH) Authorization Agreement I hereby authorize Gateway Strategies to deposit any amounts owed me by initiating credit entries to the bank account listed below in the amounts specified. Also, I authorize Gateway Strategies the right to correct any Electronic Funds Transfer resulting from an erroneous payment by debiting my account for an amount not to exceed the original amount of the erroneous credit. This authorization is to remain in force until Gateway Strategies receives written notice from me of its termination in such time and in such manner as to afford Gateway Strategies a reasonable opportunity to act on it. ******************************VENDOR INFORMATION**************************** Name (please print):_ Social Security Number: - - OR Tax ID Number: - *****************************DEPOSIT INFORMATION***************************** Check One: _ Checking Savings Requested Start Date for ACH: Check One: New _ Change Stop Bank Routing # Bank Account # ***YOU MUST ATTACH A COPY OF A VOIDED CHECK*** Signature Date GS National Insurance. 300 Bilmar Drive. Suite 200. Pittsburgh, PA Phone: (412) Fax: (412)

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16 Assignment of Commissions To Tax ID (Legal entity that Commissions are being assigned to, hereinafter the Assignee ) Assignee s Address _ City State _ Zip Code For valuable consideration, the undersigned, herein called the Assignor, hereby assigns to the Assignee all of the Assignor s right, title, interest, claim or demand in and to any and all compensation now due and payable, or which may become due and payable, under existing contracts and agreements heretofore entered into by and between Gateway Strategies (the Company ) and Assignor. Assignor hereby authorizes and empowers the Company to pay Assignee all compensation (including but not limited to over-riding commissions) now due or which may become due under the Agreement until such time as Assignor terminates this assignment by written notice to the Company. Assignor acknowledges and agrees that such payment of compensation to Assignee shall constitute payment of such compensation to the Assignor as if paid directly to the Assignor and the Company shall be fully released from any and all responsibility to the Assignor for such payments. Assignor hereby acknowledges and agrees that assignment of compensation payable under the agreement does not release or otherwise relieve Assignor of any obligation or responsibility under the Agreement including, but not limited to, the obligation to pay commissions to any applicable downline sales hierarchy and/or the obligation to reimburse the Company for compensation paid on premiums subsequently refunded. Assignor hereby covenants and agrees that the Assignor is the absolute and sole owner of said compensation, free from assignment or encumbrance of any kind or character whatsoever, and has full right and lawful authority to so assign same. The Assignor shall at all times defend, indemnify and hold harmless the Company and its officers, agents, and employees from and against any and all suits, actions, losses, damages, claims, expenses (including but not limited to the Company s legal expenses) and liability of any character, type or description arising out of the execution or performance of this agreement. Assignor Signature _ Date _ Assignor Name _ (print name) Assignee Signature Dated The Company acknowledges receipt of, and consents to the foregoing assignment, but assumes no responsibility for the validity or sufficiency hereof. This assignment is effective on the date signed by the authorized representative of the Company. By _ (signature) Dated_ Authorized Company Representative Title click here to contract