APPOINTMENT INSTRUCTIONS

Transcription

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2 APPOINTMENT INSTRUCTIONS In order to complete your appointment requests, please complete the following Agent Profile packet. Upon receipt, your information will be input into our agent database, which allows us to securely save your information. Should you ever wish to be appointed with any additional carriers in the future, we can use the information you provide here to complete contracting paperwork on your behalf, increasing speed and efficiency. We respect and value your privacy as if it were our own; we will never share your information with any person or entity outside of appointing with a carrier of your choice. By completing and signing this Agent Profile, you are attesting that the information you are providing is true and accurate and that you authorize Executive Resource Insurance Network to submit your information to your selected carriers. REQUIRED DOCUMENTS A completed Agent Profile which includes: Agent Application (2 pages) Direct Deposit/AFT form Signature Authorization Legal Questionnaire (2 pages) Advancing Authorization Employment & Address History OPTIONAL DOCUMENTS (if applicable) Assignment of Commissions form Letter(s) of Explanation for any legal questions answered with a YES Carrier Appointment Request REQUIRED SUPPORTING DOCUMENTS Clear & readable copy of your resident insurance license Clear & readable copy of your state issued driver s license Clear & readable copy of a pre-printed void check Copy of your current E&O certificate of insurance Current Anti-Money Laundering Certificate (if not completed through LIMRA)* Anti-Money Laundering training was completed via LIMRA on / / * OTHER SUPPORTING DOCUMENTS (if applicable to the carrier(s) you wish to appoint with) Clear & readable copy of any non-resident insurance license(s) Clear & readable copies of Agency insurance licenses (res/non-res) if appointing your agency. Current copies of 8-hour and 4-hour LTC certificates (if applicable) Current copy of current AHIP certificate (if applicable) Understand that once your contracting is processed by a carrier, you may also be required to complete carrier specific training and agree to complete such carrier required training in a timely manner (within thirty (30) calendar days from signature date). *If you have not met your Anti-Money Laundering requirement or need to complete the carrier specific training, please go to ERINUSA.com for the LIMRA training link. REMIT COMPLETED AGENT PROFILE & ADDITIONAL DOCUMENTATION TO: VIA TO: JENNIE@ERINUSA.COM VIA FAX TO: CONTRACTING AND APPOINTMENT QUESTIONS? CALL

3 ALL FIELDS ARE REQUIRED ~ USE BLACK INK & PRINT NEATLY RETURN USING A HIGH RESOLUTION SCANNER OR FAX MACHINE SECTION 1: AGENT INFORMATION FIRST NAME MIDDLE NAME/INITIAL LAST NAME SUFFIX DATE OF BIRTH CITY/STATE OF BIRTH SOCIAL SECURITY NUMBER DRIVERS LICENSE NUMBER STATE ISSUED EXPIRES ON MARITAL STATUS SPOUSE FIRST NAME PERSONAL ADDRESS (USED ONLY FOR VERIFICATION PURPOSES) RESIDENT ADDRESS (MUST BE STREET NO PO BOX) CITY COUNTY STATE ZIP HOME PHONE NUMBER CELL PHONE NUMBER MAILING ADDRESS (IF DIFFERENT FROM ABOVE) OR USE RESIDENT ADDRESS ABOVE AS MAILING ADDRESS BUSINESS PHONE NUMBER EXTN BUSINESS FAX NUMBER RESIDENT STATE RESIDENT STATE INSURANCE LICENSE NUMBER EXPIRES ON *NPR NUMBER YEARS LICENSED? BUSINESS (USED FOR COMMUNICATION) OR USE PERSONAL ABOVE *Your National Producer Number (NPR) is required and can be obtained via SECTION 2: LICENSING AND CERTIFICATION INFORMATION TYPE OF LICENSE(S) HELD: AGENT BROKER SOLICITOR OTHER: INSURANCE LINE(S): LIFE ACCIDENT/HEALTH LIFE/ACCIDENT/HEALTH ANNUITY OTHER: NON-RESIDENT LICENSE(S): ARE YOU REGISTERED IN THE MARKET EXCHANGES? YES NO AHIP CERIFICATION: AHIP GORMAN NOT AHIP CERTIFIED (Please Provide Certificate!) AML (Anti-Money Laundering): COMPLETED VIA LIMRA.COM COMPLETION DATE: NOT AML CERTIFIED COMPLETED VIA (PROVIDER NAME:) (Please Provide Certificate!) LTC (Long Term Care): Name of Provider: 8 HOUR CE 4 HOUR CE NOT LTC CERTIFIED (Please Provide Certificate!) For further information regarding AHIP, AML or LTC certification, please SUPPORT@ERINUSA.COM ERINAP rev

4 COMPLETE SECTION 3 ONLY IF YOU ARE PAYING COMMISSIONS TO AN AGENCY OR CORPORATION WITH A TAX ID NUMBER- IF NOT, GO TO SECTION 4 BELOW. SECTION 3: AGENCY/CORPORATION INFORMATION AGENCY/CORPORATE NAME TYPE OF BUSINESS ENTITY: C CORPORATION S CORPORATION PARTNERSHIP LLC OTHER TAX ID / EMPLOYER ID NUMBER ENTITY IS LICENSED INSURANCE AGENCY? YES (Please provide copy) NO (Please See Commission Section below) AGENCY LICENSE NUMBER STATE EXPIRES AGENCY NRP NUMBER BUSINESS ADDRESS (IF DIFFERENT THAN MAILING ADDRESS IN SECTION 1) CITY COUNTY STATE ZIP LIST OFFICERS/PARTNERS: NAME: TITLE: PRINCIPAL % INTEREST: NAME: TITLE: % INTEREST: NAME: TITLE: % INTEREST: NAME: TITLE: % INTEREST: NUMBER OF EMPLOYEES NUMBER OF LICENSED AGENTS EMPLOYED PRIMARY MARKET SECTION 4: APPOINTMENT AND COMMISSION INFORMATION PLEASE READ: MOST CARRIERS WILL REQUIRE THAT YOUR AGENCY/CORPORATION IS A LICENSED INSURANCE ENTITY AND PROOF WILL BE REQUIRED (COPY OF STATE AGENCY LICENSE(S) YOUR CORPORATION HOLDS) IF YOU WISH FOR YOUR AGENCY/CORPORATION TO BE APPOINTED AS WELL AS YOURSELF. IF YOU ARE SIMPLY WANTING TO HAVE YOUR COMMISSIONS PAID TO YOUR AGENCY/CORPORATION, SOME CARRIERS WILL ALLOW AN ASSIGNMENT OF COMMISSION TO YOUR AGENCY/CORPORATION WITHOUT HAVING TO APPOINT YOUR AGENCY AS A SEPARATE ENTITY. IN MOST CASES, PAYING COMMSSIONS TO YOUR AGENCY/CORPORATION CAN BE DONE WITHOUT HAVING TO APPOINT YOUR AGENCY/CORPORATION. A B C PLEASE CHECK ONLY ONE OPTION: I DO NOT WISH TO APPOINT MY AGENCY/CORPORATION. I WANT ANY COMMISSIONS EARNED BY MYSELF AS AN AGENT PAYABLE TO ONLY MYSELF INDIVIDUALLY USING MY SOCIAL SECURITY NUMBER. I DO NOT WISH TO APPOINT MY AGENCY/CORPORATION. I ONLY WANT ANY COMMISSIONS EARNED PAYABLE TO A THIRD PARTY ENTITY (MY AGENCY/CORPORATION) WITH A FEDERAL TAX ID/EMPLOYER TAX ID NUMBER. I WISH TO APPOINT MY AGENCY AS WELL AS MYSELF IN ALL FUTURE CONTRACTING (UNTIL NOTIFIED IN WRITING). MY AGENCY/CORPORATION IS A LICENSED INSURANCE ENTITY WITH A FEDERAL TAX ID/EMPLOYER ID NUMBER. PLEASE SIGN AS ACKNOWLEDGED DATED FOR OPTIONS B & C: AGENT MUST COMPLETE THE BLANKET ASSIGNMENT OF COMMISSIONS ON THE FOLLOWING PAGE ERINAP rev

5 ASSIGNMENT OF COMMISSIONS TO AGENCY/CORPORATION COMPLETE ONLY IF YOU COMPLETED SECTION 3 *AND* YOU ARE ASSIGNING COMMISSIONS TO YOUR AGENCY OR CORPORATION OTHERWISE DISREGARD THIS PAGE THIS ASSIGNMENT, dated on the day of, 20, is made by (hereinafter the ASSIGNOR ) of does hereby absolutely assign all interest in all compensation due to the Assignee named below: ASSIGNEE NAME: ADDRESS: TAX ID NUMBER: Assignor hereby authorizes Executive Resource Insurance Network, Inc to pay the sums assigned to the Assignee in accordance with the terms and conditions of Assignor s agreement(s) with each insurance carrier agreement. Assignor hereby represents that no other assignment has been made and no order of any court has been entered against Assignor s compensation in favor of Assignee or any other party. AGREED TO BY ASSIGNOR (Agent) Name SSN Title AGREED TO BY ASSIGNEE (Principal) Name TIN/EIN Title Signature Date Signature Date ERINAP rev

6 ELECTRONIC FUND TRANSFERS / DIRECT DEPOSIT BLANKET AUTHORIZATION AGENT NAME AGENCY NAME ACCOUNT NAME(S) FINANCIAL INSTITUTION BRANCH ADDRESS PHONE NUMBER ABA# (9 DIGITS) ACCOUNT NUMBER ACCOUNT TYPE BY SIGNING BELOW, I hereby authorize Executive Resource Insurance Network, Inc. (the Company ) to initiate ACH transfer entries and to credit and/or debit the account identified herein for business relating to contracts with the Company. This authorization shall remain in effect unless and until the Company has received written notification from myself that this authorization has been terminated in such time and manner to allow the Company to act. By signing below, I also represent and warrant to the Company that the person executing this release is an authorized signatory on the account referenced herein and all information regarding the account and account owner is true and correct. Furthermore, if any such electronic debt(s) should be returned by my financial institution as Non-Sufficient (NSF), I hereby authorize the Company to collect a returned item fee of $30.00 per item by electronic debit from the account identified herein. ACCOUNT OWNER SIGNATURE DATE JOINT ACCOUNT OWNER SIGNATURE (if applicable) DATE FOR CHECKING ACCOUNTS: YOU ARE REQUIRED TO SUPPLY A CLEAR, READABLE COPY OF A PRE-PRINTED VOIDED CHECK **COUNTER CHECKS ARE NOT ACCEPTABLE** FOR SAVINGS ACCOUNTS ONLY: VERIFYING THE ABA/ROUTING NUMBER AND YOUR SAVIONGS ACCOUNT NUMBER **COUNTER / DEPOSIT SLIPS ARE NOT ACCEPTABLE** YOU ARE REQUIRED TO SUPPLY A CLEAR, READABLE BANK MEMO ON BANK LETTERHEAD ERINAP rev

7 SIGNATURE AUTHORIZATION PLEASE READ THIS AUTHORIZATION, SIGN INSIDE THE CENTER OF THE BOX BELOW (STAYING INSIDE THE BOX LINES). SUBMIT THIS FORM BY FOLLOWING THE INSTRUCTIONS PROVIDED ON THE COVER PAGE OF YOUR AGENT PROFILE. I,, HEREBY AUTHORIZE EXECUTIVE RESOURCE INSURANCE NETWORK, INC (E.R.I.N.) AND ITS GENERAL AGENCY REPRESENTATIVES (THE AUTHORIZED PARTIES ) TO AFFIX OR APEND A COPY OF MY SIGNATURE AS SET FORTH BELOW TO ANY AND ALL REQUIRED SIGNATURE FIELDS ON FORMS AND AGREEMENTS OF ANY AND ALL INSURANCE CARRIERS DESIGNATED BY ME THROUGH THE COMPLETION AND SUBMISSION OF THIS FORM TO E.R.I.N. WITH AN AGENT PROFILE, OR THROUGH ANY OTHER MEANS, INCLUDING WITHOUT LIMITATION, BY OR VERBALLY. THE AUTHORIZED PARTIES SHALL BE PERMITTED TO COMPLETE AND SUBMIT ALL SUCH FORMS AND AGREEMENTS ON MY BEHALF FOR THE EXPRESS PURPOSE OF BECOMING AUTHORIZED AND APPOINTED TO SELL OR SOLICIT CARRIER INSURANCE PRODUCTS. I,, HEREBY RELEASE, INDEMNIFY AND HOLD HARMLESS THE AUTHORIZED PARTIES FROM ANY AND ALL CLAIMS, DEMANDS, LOSSES, DAMAGES, AND CAUSES OF ACTION, INCLUDING EXPENSES, COSTS AND REASONALBE ATTORNYS FEES WHICH THEY MAY SUSTAIN OR INCUR AS A RESULT OF CARRYING OUT THE AUTHORITY GRANTED HEREUNDER. BY MY SIGNATURE BELOW, I CERTIFY THAT THE INFORMATION I HAVE SUBMITTED TO THE AUTHORIZED PARTIES IS CORRECT TO THE BEST OF MY KNOWLEDGE AND I ACKNOWLEDGE THAT I HAVE READ AND REVIEWED ANY FORMS AND AGREEMENTS WHICH THE AUTHORIZED PARTIES HAVE BEEN AUTHORIZED TO AFFIX MY SIGNATURE TO. I AGREE TO INDEMNIFY AND HOLD HARMLESS ANY THIRD PARTY FROM AND AGAINST ANY AND ALL CLAIMS, DEMANDS, LOSSES, DAMAGES, AND CAUSES OF ACTION, INCLUDING EXPENSES, COSTS AND REASONALBE ATTORNYS FEES WHICH SUCH THIRD PARTY MAY SUSTAIN OR INCUR AS OF A RESULT OF ITS RELIANCE ON ANY FORM OR AGREEMENT BEARING MY SIGNATURE PURSUANT TO THIS AUTHORIZATION. PLEASE SIGN IN THE CENTER OF THE BOX BELOW STAY WITHIN THE LINES OF THE BOX. PLEASE INITIAL IN THE CENTER OF THE BOX BELOW STAY WITHIN THE LINES OF THE BOX.

8 LEGAL QUESTIONS FOR CONTRACTING/APPOINTMENT REQUESTS PLEASE ANSWER THE FOLLOWING QUESTIONS. IF YOU ANSWER YES TO ANY QUESTION, YOU MUST PROVIDE A FULL AND DETAILED EXPLANATION ON THE LETTER OF EXPLANATION PAGE FOLLOWING THESE QUESTIONS FOR EACH YES ANSWER. EXPLANATIONS SHOULD INCLUDE DATES, ACTIONS AND COMPREHENSIVE DETAILS. FEEL FREE TO USE ADDITIONAL PAPER FOR EXPLAINATIONS IF NECESSARY. CERTAIN CARRIERS WILL REQUIRE SUPPORTING DOCUMENTATION, SUCH AS BANKRUPTCY DISCHARGE PAPERS, TO ACCOMPANY CERTAIN EXPLANATIONS. NO YES 1. HAVE YOU EVER BEEN CHARGED OR CONVICTED OF OR PLEAD GUILTY OR NO CONTEST TO ANY FELONY, MISDEMEANOR, FEDERAL/STATE INSURANCE AND/OR SECURITIES OR INVESTMENTS REGULATIONS OR STATUTES? 2. HAVE YOU EVER BEEN ON PROBATION? 3. HAVE YOU EVER BEEN CHARGED, CONVICTED OF OR PLEAD GUILTY OR NO CONTEST TO ANY FELONY? 4. HAVE YOU EVER BEEN CHARGED, CONVICTED OF OR PLEAD GUILTY OR NO CONTEST TO ANY MISDEMEANOR? 5. HAVE YOU EVER BEEN CONVICTED OF OR PLEAD GUILTY OR NO CONTEST TO A VIOLATION OF FEDERAL OR STATE SECURITES OR INVESTMENT RELATED REGULATIONS? 6. HAVE YOU EVER BEEN CONVICTED OF OR PLEAD GUILTY OR NO CONTEST TO A VIOLATION OF STATE INSURANCE DEPARTMENT REGULATION OR STATUTE? 7. HAS ANY FOREIGN GOVERNMENT, COURT, REGULATORY AGENCY OR EXCHANGE EVER ENTERED AN ORDER AGAINST YOU RELATED TO INVESTMENTS OR FRAUD? 8. HAVE YOU EVER BEEN OR ARE YOU CURRENTLY BEING INVESTIGATED, HAVE ANY PENDING INDICTMENT, LAWSUITS OR HAVE YOU EVER BEEN IN A LAWSUIT WITH AN INSURANCE COMPANY? 9. ARE YOU CURRENTLY UNDER ANY INVESTIGATION BY ANY LEGAL OR REGULATORY AUTHORITY? 10. HAVE YOU EVER BEEN UNDER INVESTIGATION BY ANY INSURANCE COMPANY? 11. HAVE YOU EVER BEEN OR ARE YOU CURRENTLY INVOLVED IN ANY PENDING INDICTMENTS, LAWSUITS, CIVIL JUDGEMENTS OR OTHER LEGAL PROCEEDINGS CIVIL OR CRIMINAL? 12. HAVE YOU EVER BEEN NAMED A DEFENDANT OR CODEFENDANT IN A LAWSUIT OR HAVE YOU EVER SUED OR BEEN SUED BY ANY INSURANCE COMPANY? 13. HAVE YOU EVER BEEN ALLEGED TO HAVE BEEN ENGAGED IN ANY FRAUD? 14. HAVE YOU EVER BEEN FOUND TO HAVE ENGAGED IN ANY FRAUD? 15. HAS ANY INSURANCE OR FINANCIAL SERVICES COMPANY OR BROKER-DEALER EVER TERMINATED YOUR CONTRACT OR APPOINTMENT OR PERMITTED YOU TO RESIGN FOR ANY REASON OTHER THAN LACK OF SALES? 16. WERE YOU FIRED BECAUSE YOU WERE ACCUSED OF VIOLATING INSURANCE OR INVESTMENT RELATED STATURES, REGULATIONS, RULES OR INDUSTRY STANDARDS OF CONDUCT? 17. WERE YOU FIRED BECAUSE YOU WERE ACCUSED OF FRAUD OR WRONGFUL TAKING OF PROPERTY? 18. FAILURE TO SUPERVISE IN CONNECTION WITH INSURANCE OR INVESTMENT RELATED STATUTES, REGULATIONS, RULES OR INDUSTRY STANDARDS OF CONDUCT? 19. HAVE YOU EVER HAD AN APPOINTMENT WITH ANY INSURANCE COMPANY DENIED? 20. HAVE YOU EVER HAD AN APPOINTMENT WITH ANY INSURANCE COMPANY TERMINATED FOR CAUSE? 21. DOES ANY INSURER, INSURED OR OTHER PERSON(S) CLAIM ANY COMMISSION CHARGEBACK OR OTHER INDEBTEDNESS FROM YOU AS A RESULT OF ANY INSURANCE TRANSACTIONS OR BUSINESS?

9 NO YES 22. HAS ANY LAWSUIT OR CLAIM EVER BEEN MADE AGAINST YOU, YOUR SURETY COMPANY OR ERRORS AND OMISSIONS INSURER ARISING OUT OF YOUR SALES OR PRACTICES? 23. HAVE YOU EVER BEEN REFUSED SURETY BONDING OR ERRORS AND OMISSIONS COVERAGE? 24. HAS A BONDING OR SURETY COMPANY EVER DENIED, PAID ON OR REVOKED A BOND FOR YOU? 25. HAS ANY ERRORS & OMISSIONS CARRIER EVER DENIED, PAID CLAIMS ON OR CANCELLED YOUR COVERAGE? 26. HAVE YOU EVER HAD AN INSURANCE OR SECURITIES LICENSE DENIED, SUSPENDED, CANCELLED OR REVOKED FOR ANY REASON? 27. HAS ANY STATE OR FEDERAL REGULATORY BODY FOUND YOU TO HAVE BEEN A CAUSE OF AN INVESTMENT-OR INSURANCE-RELATED BUSINESS HAVING ITS AUTHORIZATION TO DO BUSINESS DENIED, SUSPENDED, REVOKED OR RESTRICTED AT ANY TIME? 28. HAS ANY STATE OR FEDERAL REGULATORY BODY REVOKED OR SUSPENDED YOUR LICENSE AS AN ATTORNEY, ACCOUNTANT OR FEDERAL CONTRACTOR? 29. HAS ANY STATE OR FEDERAL REGULATORY BODY FOUND YOU TO HAVE MADE ANY TYPE OF FALSE STATEMENT OR OMISSION OR TO HAVE BEEN DISHONEST, UNFAIR OR UNETHICAL? 30. HAVE YOU EVER HAD ANY INTERRUPTIONS IN LICENSING? 31. HAS ANY STATE, FEDERAL OR SELF-REGULATORY BODY FILED A COMPLAINT AGAINST YOU, FINED, SANCTIONED, CENSURED, PENALIZED OR OTHERWISE DISCIPLINED YOU FOR ANY VIOLATION OF THEIR REGULATIONS OR STATE OR FEDERAL STATUTES? 32. HAVE YOU EVER BEEN THE SUBJECT OF A CONSUMER INITIATED COMPLAINT? 33. HAVE YOU EVER PERSONALLY FILED A BANKRUPTCY PETITION OR DECLARED BANKRUPTCY? 34. HAS ANY INSURANCE OR SECURITIES BROKERAGE FIRM WITH WHOM YOU HAVE BEEN ASSOCIATED FILE A BANKRUPTCY PETITION OR BEEN DECLARED BANKRUPT EITHER DURING YOUR ASSOCIATION OR WITHIN FIVE YEARS AFTER TERMINATION OF SUCH ASSOCIATION? 35. IS THERE A BANKRUPTCY PENDING OR NOT YET FILED? 36. ARE THERE ANY UNSATISFIED JUDGEMENTS, GARNISHMENTS OR LIENS AGAINST YOU? 37. ARE YOU CONNECTED IN ANY WAY WITH A BANK, SAVING & LOAN ASSOCIATION OR OTHER LENDING OR FINANCIAL INSTITUTION? 38. HAVE YOU EVER USED ANY OTHER NAMES OR ALIASES? 39. DO YOU HAVE ANY UNRESOLVED MATTERS PENDING OR ONGOING WITH THE INTERNAL REVENUE SERVICE OR ANY OTHER TAXING AUTHORITY? 40. DID YOU ACTUALLY READ ALL OF THESE QUESTIONS? ****IF YOU ANSWERED YES TO ANY QUESTION ABOVE, YOU MUST PROVIDE A FULL AND DETAILED EXPLANATION**** ON THE LETTER OF EXPLANATION PAGE FOLLOWING THESE QUESTIONS *OR* A SEPARATE SHEET FOR EACH ANSWER. I attest that the information I have provided is true and correct to the best of my knowledge. I hereby authorize Executive Resource Insurance Network and its representatives to provide this information to the carriers I choose to appoint with and understand that they may contact me when or if I may ever need to answer any carrier specific questions not covered or asked above. I acknowledge that if any information changes, I will notify Executive Resource Insurance Network within five days of such change and provide any requested supporting materials. PRINT NAME SIGNATURE DATE:

10 PLEASE USE THIS SHEET AS YOUR LETTER OF EXPLANATION FOR ANY BACKGROUND QUESTION(S) ANSWERED WITH YES. MAKE AS MANY COPIES AS NEEDED TO EXPLAIN EACH/ALL YES QUESTION(S) AND SUBMIT ALONG WITH ANY SUPPORTING DOCUMENTATION IF AVAILABLE. AGENT NAME: EXPLANATION IN RELATION TO QUESTION # ACTION: DATE(S): EXPLANATION: IN ADDITION, IF LOE PERTAINS TO A BANKRUPTCY: CHAPTER FILED ON / / AND DISCHARGED ON / / OR NOT DISCHARGED AGENT SIGNATURE: DATED: PLEASE USE THIS SHEET AS YOUR LETTER OF EXPLANATION FOR ANY BACKGROUND QUESTION(S) ANSWERED WITH YES. MAKE AS MANY COPIES AS NEEDED TO EXPLAIN EACH/ALL YES QUESTION(S) AND SUBMIT ALONG WITH ANY SUPPORTING DOCUMENTATION IF AVAILABLE. AGENT NAME: EXPLANATION IN RELATION TO QUESTION # ACTION: DATE(S): EXPLANATION: IN ADDITION, IF LOE PERTAINS TO A BANKRUPTCY: CHAPTER FILED ON / / AND DISCHARGED ON / / OR NOT DISCHARGED AGENT SIGNATURE: DATED:

11 What are Advanced Commissions? ADVANCED COMMISSIONS Executive Resource Insurance Network, Inc. is proud to offer advanced commissions for certain carriers. We want to make every agent or agency aware that advanced commissions are usually a loan from the carrier based on your clients continuation in paying their modal premiums. Because it is a loan, a lot of carriers will charge a fee. The amount of the fee is strictly up to the individual carrier. Some charge a fee of 3-5% of the dollar amount advanced. For example, if a carrier were to advance you $1,000 they would charge a $50 advance fee and give you $950. Carriers can also base the advance calculation on the annual premium, not the modal. Therefore, you would lose out on the difference between the modal and the annual premium. The annual premium does not always equal the monthly premium times 12. We encourage all agents to make sure that know exactly what the carrier will charge for any advance. Agents must understand and acknowledge the following: Not all carrier offer advance commissions. The carrier will conduct various background checks and upon completion, it is at the sole discretion of the carrier or Executive Resource Insurance Network to accept or reject the proposed request for advancement of commissions. If a request for advance commissions is requested after business is submitted, the carrier and/or Executive Resource Insurance Network cannot guarantee the advancement request will be processed to include any prior business submitted. The agent is liable to the carrier or Executive Resource Insurance Network for any overpayment of commissions that occurs as a result of advances and the agent agrees that the carrier or Executive Resource Insurance Network will recapture and/or recoup commissions in accordance with existing lapse or cancellation rules for in-force policies. If the agent does not pay all amounts due to the carrier and/or Executive Resource Insurance Network, all means necessary will be utilized to collect the debt after demand for payment. All debts will be reprted to Vector. PLEASE READ AND CHECK APPROPRIATE BOXES: I would like a standing order for any contracting to INCLUDE a request for advance commissions with contracting submitted until otherwise informed in writing by me. I would like a standing order for any contracting to NOT INCLUDE a request for advance commissions with contracting submitted until otherwise informed in writing by me. Executive Resource Insurance Network can terminate advances under this Addendum immediately at their sole discretion. If this happens, the agent will receive a notice of the termination. Upon termination of advances under this Addendum, all advances shall cease and the advance debt reduced until a zero balance is attained. If agent does not continue writing business to repay the advance debt, a payment plan must be arranged and agreed to for any remaining balance owed. I UNDERSTAND AND ACKNOWLEDGE THE GUIDELINES FOR ADVANCED COMMISSIONS AS OUTLINED ABOVE: AGENT NAME: DATE: AGENT SIGNATURE:

12 EMPLOYMENT HISTORY Please provide 7 years of employment history below. Use additional sheet if necessary. Employer/Company: Position: Employer/Company: Position: Employer/Company: Position: Employer/Company: Position: ADDRESS HISTORY Please provide 7 years of address history below. Use additional sheet if necessary.

13 CERTIFICATION & TRAINING Please be sure that you have completed the required certification and training prior to soliciting or writing any new business. The below information is for your reference in helping you to complete these requirements. TRAINING TYPE Anti-Money Laundering (AML) WHAT IS IT? Agents must complete this certification annually to meet PATRIOT Act requirements. NAIC Suitability Many states that have adopted the model NAIC regulation, or part of it, have also enacted part of the continuing education (CE) element as part of the licensing requirement for that state. Carriers also require Annuity Product training. Continuing Education WebCE delivers over half a million courses annually and offers the largest nationwide Catalog of approved courses to satisfy any state Specific subject requirements on topics such as Ethics, law, annuities, variable products and LTC Partnership training. MAPD-PDP Carrier Certifications Training needs to completed for Aetna, Cigna, Coventry, Humana, United HealthCare, Universal Healthcare. Does your state require CE & Carrier Product Training?

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15 CARRIER APPOINTMENT REQUEST TO ENSURE THAT YOUR CONTRACTING PAPERWORK IS THE MOST CURRENT VERSION AND IS PROCESSED AS QUICKLY AS POSSIBLE, PLEASE BE SURE TO COMPLETE ANY OUTSTANDING CONTRACTING WITHIN THIRTY (30) DAYS. PLEASE NOTE CERTAIN CARRIERS REQUIRE NEW BUSINESS BE SUBMITTED WITH YOUR CONTRACTING AND WE WILL NOT SUBMIT THOSE CONTRACTS UNTIL NEW BUSINESS IS RECEIVED IN OUR OFFICE. FINAL EXPENSE CARRIERS: 5 Star^ American Continental Americo Assurity* Baltimore Life Foresters Forethought Gerber Life^* (GI) Kemper^ (GI) Liberty Bankers Life Medico Oxford Life^ Royal Neighbors^ Sentinel Life Settlers Life^ Standard Life^ Stonebridge Transamerica UCT^ United Home Life United of Omaha (Legacy Safeguard) Washington National LIFE INSURANCE CARRIERS: Allianz^ American General*^ Americo^ ANICO^ Assurity*^ Aviva^ Baltimore Life Banner Life^ Foresters*^ Genworth*^ ING Midland National^ Minnesota Life^ Mutual of Omaha^ Natl Western Life^ North American^ Oxford Life*^ Protective Life*^ Royal Neighbors^ Sagicor Life Transamerica^ MEDICARE SUPPLEMENT CARRIERS: Aetna (American Continental) Aflac^ Assured Life Cigna (ARLIC)^ Columbian Mutual*^ Combined^ Equitable Life^ Forethought*^ Gerber^ Heartland National^ Medico^ Mutual of Omaha^ Oxford Life^ Sentinel Life^ Sterling^ Stonebridge^ United American United Healthcare MEDICARE ADVANTAGE & PRESCRIPTION DRUG: Aetna^ CarePlus^ Care Improvement +^ Cigna Healthspring^ Cigna Rx^ Excellus^ (NY only) Coventry^ Freedom/Optimum FL Healthcare Plus^ Humana^ Piedmont WellStar (GA only) PUP Preferred Care Part^ United Healthcare^ Silverscript^ Simply^ Wellcare DENTAL INSURANCE CARRIERS: Assurant DP Dental (Online) Foundation Dental Medico Security Life (PPO) Metlife Dental (DMO) Secure Dental One (PPO) SUPPLEMENTAL CARRIERS: American General*^ Assurant^ Assurity*^ GTL* HealthIns Innovations^ Heartland^ IHC Health Solutions^ Kemper^ Medico^ Washington Mutual^ LONG TERM CARE CARRIERS: American General*^ Genworth*^ John Hancock*^ MedAmerica^ Mutual of Omaha^ Transamerica^ ANNUITY CARRIERS: We contract with most annuity carriers. Please indicate the name(s) of the annuity carriers you are interested in contracting with: ***We offer the best CD replacement MYGA s available through Liberty Bankers, Sentinel Security & Bankers Life.*** Please contact us for the most current rates. Please Note: *Carriers require new business be submitted with a new agent appointment contract Your contract will not be submitted to the carrier until business is received by our office. ^ Current E&O certificate of Insurance is required to appoint. AGENT NAME: RESIDENT LICENSE NUMBER: ADDRESS: DATE: / /