PEO Insurance Brokers Network looks forward to doing business with your agency and beginning a great working relationship.

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1 Dear Referral Partner: PEO Insurance Brokers Network looks forward to doing business with your agency and beginning a great working relationship. CHECKLIST Legible copy of your current broker s license Legible copy of your broker s bond (If applicable) Copy of your current E & O policy declaration page Completed brokerage contract Completed producer questionnaire Completed W-9 form Please send the completed information to: PEO Insurance Brokers Network Fax: quotes@peobrokersnetwork.com

2 Referral Partner Questionnaire Page 1 of 2 Legal Agency Name: DBA: Mailing Address: Street Address: Phone Number: Fax Number: Agency Type: Retail Whole Sale Both Agency is a: Partnership Sole Proprietorship Corporation S-Corp Date Agency Established: Federal ID or Sec. No.: Name and addresses of all persons having an ownership interest in agency. Please attach additional sheets if necessary. Name of Owner/Principal: Home Address: City: State: Zip: Total number of employees: Total number of producers Key Employees: Name: Title

3 Producer Questionnaire Page 2 of 2 Have you or anyone in your agency been sued concerning insurance related activities? Yes No If yes, please explain on a separate sheet and attach to this form Have you, your employees, or your agency ever been disciplined by any State Agency or Department of Insurance? Yes No If yes, please explain on a separate sheet and attach to this form Has any Errors & Omission claims been made in the most recent five years against your agency, officer, partners or owners? Yes No If yes, please explain on a separate sheet and attach to this form Financial Information: Bank Name: Mailing Address: City State Zip Routing # Trust Account # Average Balance: $ Do you have overdraft protection? Yes No Please list companies and MGA s you place business with in order of premium Carrier/ MGA: Annual Premium: Loss Ratio

4 It is agreed that the statements on this application or any material submitted herewith are true and accurate representation of the applicant and they shall be deemed material to the acceptance of risk(s) from the brokerage by PEO Insurance Brokers Network Name (please print): Title: Signature: Date:

5 Limited Referral Partner Agreement This agreement is made and entered between PEO Insurance Brokers Network and Referral Partner: Mailing address: Hereinafter producer 1. Producer shall have no authority to bind any coverages on new or renewal business or claim hereunder, or make any changes in terms and conditions of any policy of insurance 2. Producer shall have no authority to issue a binder in the name of PEO Insurance Brokers Network or any company represented by PEO Insurance Brokers Network 3. In the event an unauthorized binder issued by the producer through PEO Insurance Brokers Network or any company represented by PEO Insurance Brokers Network, suffers loss, producer agrees to indemnify, hold harmless and defend PEO Insurance Brokers Network and/or any company represented by PEO Insurance Brokers Network against any judgment or settlement and for all loss and expense, including but not limited to, attorney fees and investigation costs, incurred by PEO Insurance Brokers Network or any company represented by in the payment or defense or claim or loss resulting from said unauthorized binder. 4. PEO Insurance Brokers Network will allow producer commissions at such rates as agreed to between parties hereto. In the event of any return premium becoming due for any reason whatsoever, producer shall refund any associated commission to PEO Insurance Brokers Network at the same rate at which the commission was originally allowed. It is agreed that there will be no commission paid on any policy fees, taxes or other fees added to the policy. 5. Producer agrees that no flat cancellation shall be allowed. Producer will pay to PEO Insurance Brokers Network any and all open accounts, accounts stated or other indebtedness arising out of or relating to policies of insurance under this agreement. Producer further guarantees to pay earned premiums (Including minimum premiums and collected audit premium) and all other fees and charges for the time coverage is in force and effect on any and all insurance policies written through facilities of PEO Insurance Brokers Network. Producer shall be responsible for arranging for the return to the insured any unearned premium and unearned commissions that belong to the insured. Producer shall remit all payments to PEO Insurance Brokers Network within 10 days of producers receipt of such payment. Producer shall hold all payments received from insured in trust until payments are transmitted to PEO Insurance Brokers Network. No payment accepted or received by producer shall be deemed paid to PEO Insurance Brokers Network until such payment shall be received in hand PEO Insurance Brokers Network. Any violation

6 of the foregoing shall be considered a breach of the producer s fiduciary responsibilities and obligations to PEO Insurance Brokers Network and its insurance companies and MGA(s). Producer recognizes that any violation of the terms of this paragraph shall be sufficient cause for rescission of this agreement. 6. The producer may submit business from the State of California. It is agreed that within California, the producer shall be free to exercise his/her judgment as to the person (s) solicited and the time, manner, means and place of solicitations, and PEO Insurance Brokers Network shall not be responsible for any expenses incurred by the producer in such solicitations, or any brokerage expense. 7. The producer is not an agent; employee or representative of PEO Insurance Brokers Network or nay company represented by PEO Insurance Brokers Network. No act of the producer shall be binding on PEO Insurance Brokers Network or any company represented by PEO Insurance Brokers Network. The producer represents that he/she is fully authorized under the laws of the State of California. The producer shall be transacting business on behalf of his/her client and not PEO Insurance Brokers Network. 8. PEO Insurance Brokers Network will take reasonable steps to give the producer reasonable advance notice of the expiration of all policies, but failure to provide such notice shall not render PEO Insurance Brokers Network liable in the regard. So long as the producer remains current, accounting for and paying all accounts for which he/she is liable, the producers records and use and control of expiration(s) shall be deemed the property of the producer and remain in his/her sole possession, and control. In the event that the producer defaults on any accounts for which he/she may be liable, PEO Insurance Brokers Network has the right to cancel, revoke, or rescind this agreement and immediately retain control of any and all accounts in default, which are in the producer s possession and control. 9. Producer agrees to indemnify and hold harmless PEO Insurance Brokers Network, any of its employees, agents, underwriting companies, claim adjusting companies, or insurance companies, from and against any and all claims arising out of or relating to any alleged act or alleged failure to act by the producer which results in any claim, loss, aware, penalty, demand, action or cause of action be meritorious. Producer agrees to promptly notify PEO Insurance Brokers Network of any claim, demand, action or cause of action made against producer. Producer agrees to indemnify PEO Insurance Brokers Network and/or any of its underwriting companies, claim adjusting companies or insurance companies from any and all loss, expense, settlement or judgment including expense of investigators, expert witnesses, court costs, and attorney fees arising from or relation to any alleged failure to act on the part of the producer whether or not said claim, loss, award, penalty, demand, action or cause of action be meritorious.

7 10. Producer agrees to indemnify and hold harmless PEO Insurance Brokers Network, its shareholders, directors, and employees, against any and all claims, demands, actions, liability, losses, damages, penalties, judgments, costs and expenses, PEO Insurance Brokers Network limitation, attorney fees, disbursements and court costs, made or instituted against, by PEO Insurance Brokers Network, its shareholders, directors and employees which arise directly or indirectly out of any act or omission of the producer, or its employees or representatives. 11. PEO Insurance Brokers Network agrees to indemnify and hold harmless producer, any of its employees, agents, or representatives, from and against any and all claims arising out of or relation to any alleged act or alleged failure to act by PEO Insurance Brokers Network, which results in any claim, loss, award, penalty, demand, action or cause of action against producer or any of its employees, agents, or representatives, whether or not said claim, loss, award, penalty, demand, action or cause of action be meritorious. PEO Insurance Brokers Network agrees to promptly notify producer of any claim, demand, action or cause of action made against PEO Insurance Brokers Network. PEO Insurance Brokers Network agrees to indemnify producer, any of its employees, agents, or representatives from any and all loss, expense, settlement or judgement including expenses or investigators, expert witnesses, court costs, and attorney fees arising from or relating to any alleged failure to act on the part of the PEO Insurance Brokers Network, whether or not said claim, loss, award, penalty, demand, action or cause of action be meritorious. 12. Producer agrees to indemnify and hold harmless PEO Insurance Brokers Network, any of its employees, agents, underwriting companies, claim adjusting companies, or insurance companies, from and against any and all claims arising out of or relating to any alleged act or alleged failure to act by a producer, in reliance on the producer s capacity as power of attorney for any third party, which results in any claim, loss, award, penalty, demand, action or cause of action against PEO Insurance Brokers Network or its underwriting companies, claim adjusting companies, or insurance companies, whether or not said claim, loss, award, penalty, demand, action or cause of action be meritorious. 13. PEO Insurance Brokers Network agrees to indemnify and hold harmless producer, its employees, agents, or representatives against and in respect of any and all claims, demands, actions, liability, losses, damages, penalties, judgments, costs and expenses, including without limitation, attorney fees, disbursements and court costs, made or instituted against, or incurred by producer, its employees, agents, or representatives, which arise directly or indirectly out of any act or omission of PEO Insurance Brokers Network, or its employees or representatives. 14. Producer in placing business under this agreement recognizes that producer is a representative of the insured and is not acting as an agent or representative of PEO Insurance Brokers Network or its insurance companies, or claim adjusting companies. 15. Neither PEO Insurance Brokers Network nor the insurance company shall bear responsibility for any expense incurred by producer, regardless of the origin of the expense incurred.

8 16. Producer shall abide by the California Fair Claims Settlement Practices Regulations when handling claims. 17. In the event of any dispute arising between the parties relating to this agreement, it is agreed that the only venue for litigation shall be Orange County, California. It is also agreed that the prevailing party in any such litigation shall be entitled to recover all reasonable attorney fees, legal fees and costs, and other expenses arising out of such action. 18. Producer agrees that producer will provide each insured with an explanation of the terms and provisions of the policy of insurance including, but not limited to coverage being afforded, amendments and exclusions contained within the policy of insurance. 19. Producer shall not reproduce and/or distribute any sample insurance policies to nay party, other than a prospective insured in the normal course of business. Producer shall not post or cause to be posted, any sample policy or current policy of an insured on the internet or any internet website at any time. 20. Producer agrees to keep in full force and effect an errors and omissions insurance policy with limits no less than $1,000,000 during the full term of this agreement and if requested will send a copy of the policies to PEO Insurance Brokers Network. 21. In the event any provision of this agreement shall be held illegal or invalid for any reason, the illegality or invalidity shall not affect the remaining parts of the agreement, and the agreement shall be construed and enforced as I the illegal or invalid provision(s) had not been included. 22. This agreement superseded and replaces any and all previous agreements and shall be effective as of the date entered below and shall remain in full force and effect until cancellation/ Cancellation may be effectuated by wither party providing written notice of cancellation by mail to the party s last known address. Cancellation of this agreement will become effective after the date of mailing and any such cancellation shall comply with the laws of the State of California. 23. Failure to abide by all the terms and conditions of this agreement will result in the immediate suspension or termination of this producer agreement, at the sole discretion of PEO Insurance Brokers Network.

9 In witness whereof, the parties hereby enter into this agreement on This day of year PEO Insurance Brokers Network Signature: Print Name: Title: Producer IRS # Signature: Print Name: Title:

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