Please fax completed forms to New Agent Appointments fax# or send by

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1 Please fax completed forms to New Agent Appointments fax# or send by For questions regarding the appointment forms please call Bobbie For questions about services and carriers contact us at Marketing@combinedgroup.com New Agent Checklist: Items required for all agent appointments: Agency Information form Completed and signed Agency Agreement W-9 form Copy of current Property & Casualty producer s license Copy of agent s current driver s license (carrier mandate) Copy of current E&O policy (minimum coverage $1 million) Address form Direct Deposit Authorization form * (Optional) CIA Pay Express Authorization form * (Optional) Agent Direct Express form (Use only if you are directly appointed with one or more of the carriers listed) $150 per user per month *Must include copy of voided check or deposit slip for processing Internal use only: Date Webinar Attended: Agency Name: Assigned Agent number: Password: State: Assigned Marketing Rep: Preston Rd., #350 Dallas, TX Phone: Fax: Toll Free: Fax:

2 Agency Information Form: Name: Physical Address: Mailing Address: (all correspondence sent here) Street/ Street: P.O. Box: City: City: State: Zip: State: Zip: Phone #: Fax #: There are times documents from our office are ed rather than faxed or posted. Please provide one address below where we may send these items If you would rather receive all faxes via this address please check box. **Please note all correspondence and documents for all policies, that are normally faxed, will be sent to this one if you select this option. ** Contact name for accounting purposes: Year established: Web Site: Total Annual Commercial Premium Volume for all locations: Expected Annual Commercial Premium Volume to place with CG: If you have a Combined Group Mktg. Rep. please advise: In order to better serve you, please indicate what needs you have in an MGA. Check All that apply: Online quoting: WC: Non- Subscription: E & S Lines: Standard Lines: All: Other (please specify): Preston Rd., #350 Dallas, TX Phone: Fax: Toll Free: Fax:

3 AGENCY AGREEMENT This Agreement is made and entered into by and between Combined Group Insurance Services, Inc. and CIA Managing General Agencies both of Dallas, Texas ( Company ), and doing business as (if applicable), located in ("Agent ). The purpose of this Agreement is to state the terms and conditions under which the Agent has been appointed as an agent of the Company for the solicitation and servicing of contracts of insurance for the Company and insurers the Company represents. Accordingly, the Company and the Agent hereby agree as follows: 1. Premium Payment. On all Company billed business, the Agent agrees to pay the Company, its successors or assigns at Dallas, Texas, all premiums, taxes, fees, and other sums due or to become due to the Company. The amount due in payment and the terms and conditions regarding such payment shall be as per an invoice presented to the Agent upon binding coverage. The amounts due the Company shall be the written new business, renewal, and additional premium endorsements plus fees and taxes, less return premium endorsement(s) and commissions allowed to the Agent per the policy quotation. On all policy cancellations, the Company shall credit the Agent s account for all return premiums received from the insurance company, less amounts due any premium finance company or return commissions due back from the Agent. The Agent may be obligated to pay premiums for policies bound by the Agent in the following ways: a. Cash With Application the Agent must remit payment to the Company for the entire amount due per the terms and timing indicated on the invoice provided by the Company. Said invoice shall indicate the rate of commission and whether commission may be deducted by the Agent from payment to the Company. b. Account Current -The Agent may apply to become an account current Agent, and all invoices not otherwise identifying payment as Cash with Application may be paid per the Agent s monthly statement as provided by the Company. The Agent must apply to the Company to become an Account Current Agent by completing an application and providing documents including, but not limited to, financial statements, authorization to obtain credit information, evidence of valid/in-force errors and omissions coverage, and having been an insurance agent as his/her primary business for at least four (4) years. All sums for such items shall be due and payable on the twenty-fifth (25th) day from the end of the month following the appearance of said items on the Company-prepared monthly Accounting Statement detailing all premium transactions. In the event the Agent's payment has not been received by the Company for all sums due the Company by the said due date, then the Company reserves the right to terminate or suspend the Agreement as of that date, and/or cancel policy coverage for unpaid accounts. In the event of termination for non-payment as detailed in this Section, the requirement of ten (10) days written notice does not apply. The Company reserves the right to charge interest of up to the maximum legal limit on any amounts thirty (30) days or more past due. c. Direct billed - Policies shall be billed by the insurer directly to the insured, and commissions shall be remitted directly to the Agent by the Company or the insurer, depending upon the program. 2. Payments from Agent to Company (PayExpress). Agent agrees to initiate settlement of amounts due to pay all premiums, taxes, fees, and other sums as approved by the Agent other than on direct billed business. Agent may elect to complete CIA PayExpress Authorization Form and remit it, along with all required documentation, to the Company along with this Agreement. The Company may not debit the Agent s bank account for any amount due, unless specifically authorized by the Agent. On all business bound by Cash with Application Agents, the Company, upon receiving authorization from the Agent, may debit Agent s account per the date specified on the invoice sent to the Agent for the policy. 3. Payments from Company to Agent (Direct Deposit). Agent agrees to maintain current bank information on file with the Company for direct deposit of commissions, premium refunds, overpayments, and any other sums deemed payable by Company to Agent. Agent shall complete Authorization for Direct Deposit (EFT) and remit it along with required documentation, to the Company along with this Agreement. 4. Independent Contractor. The Agent agrees to perform all duties and to follow all instructions faithfully as an Agent for the Company, but it is understood that the Agent's actions shall be in the capacity of an independent contractor and in no way interpreted as those of an employee or servant of the Company. 5. Agent s Authority. The Agent's authority to solicit and accept applications for insurance coverage on behalf of the Company shall extend only to the lines of business, classes of risks, and limits of liability authorized by the Company. This authorization to solicit and accept applications shall be detailed on various underwriting guidelines, rate charts, internet web sites, and other written instructions as directed by the Company as it deems necessary, including Exhibit A to this Agreement detailing the Company s Small Business and Middle Market Programs. The Agent shall have no binding authority whatsoever and shall not represent to any insured that a risk is bound prior to written acceptance by the Company. Agent shall present to Company a full and accurate application on all risks presented to the Company, and shall use best efforts to ascertain that all information presented is accurate and fairly presented to Copyright 2008 Combined Group Insurance Services, Inc. Page 1 of 6 Version 2.03 H2115

4 the Company. The Agent agrees to indemnify, defend, and hold the Company and any of its insurers harmless for the material misrepresentation of any risk if the Agent knew or should have known that information contained on an application of insurance was false, misstated, or understated so as to cause the Company or its insurers to become unable to collect all premiums due or to accept a risk that would have been unacceptable based on various underwriting guidelines, rate charts, internet web sites, and other written instructions as directed by the Company. 6. Agent as Fiduciary for Company and Insurers. All premiums and return premiums received by the Agent either before, during or after the termination of this Agreement shall be held by the Agent in a fiduciary capacity as trustee for the Company. A separate Premium Account shall be established to control these funds for the Company, or for insureds in the case of return premiums. These funds shall not be co-mingled with other funds of the Agent or used for any purpose other than as designated above. The keeping of an account with the Agent on the Company books in the form of a debtor-creditor account is to be deemed merely a record of business transacted. Neither the keeping of an account in such form, nor the rendering of same, nor failure to enforce prompt remittance, nor alteration in compensation rate, nor the retention of commission by the Agent, nor compromise or settlement shall be held to waive assertion of the trust relationship as to premiums collected by the Agent. The Agent agrees that the Agent is responsible for, and guarantees to the Company, payment of all earned premiums on policies placed by this Agent with the Company. The Agent further agrees to pay all amounts due as return commission on cancelled policies or reductions in premiums to the Company on Company-billed policies and to the insurer on direct billed policies at the same rate at which commissions were originally retained by Agent or paid by the insurer to Agent. 7. Errors and Omissions Coverage. The Agent shall maintain Insurance Agents Errors and Omissions insurance coverage in an amount not less than $1,000,000 with an insurance company rated A- VII or higher by A.M. Best at all times during which this Agreement is in effect. Agent shall provide a certificate of insurance to the Company evidencing such Errors and Omissions Insurance is in force at the time this Agreement is signed, and shall send the Company a certificate of insurance evidencing each subsequent renewal of said coverage. Should the Agent fail to renew the Insurance Agents Errors and Omissions coverage and provide the Company with a new certificate, this Agreement may be cancelled without additional notice as of the date said insurance coverage expires. 8. Licensing. Agent shall maintain a current, valid insurance agent s license sufficient for the Agent to be an insurance agent for property and liability Insurance business, issued pursuant to the laws of the state in which Agent is domiciled. Should Agent s license lapse or be revoked at any time by the state of Agent s domicile, this Agreement may be cancelled without additional notice as of the date said license is no longer in force. 9. Expenses. The Company shall not be responsible for any expenses whatsoever incurred by the Agent unless specified by written agreement prior to the date such expenses were incurred. 10. Company Supplies. Any policy forms or other Company supplies furnished to the Agent by the Company shall always remain the property of the Company and shall be returned to the Company or its representatives promptly upon demand. Upon termination of this Agreement, the Agent shall promptly deliver all property of the Company to the Company or its authorized representatives. 11. Notice of Claims. The Agent shall promptly forward written notice to the Company of any claim of which he has knowledge, but shall under no circumstances advise any insured or third party as to whether or not any claim is covered. The Company, when appointed by the insurer, shall retain sole right to investigate, determine validity of coverage, adjust, settle, compromise, and pay all claims on policies issued under the terms of this Agreement. The Agent shall immediately forward all notices of suits, demands, State Board Complaints, or letters from Attorneys to the Company on all matters concerning the Company, its policies or insureds, or activities of the Agent. The Agent agrees to defend, indemnify and hold the Company harmless for any and all violations of this Section. All correspondence relating to suits, demands, State Board Complaints must be provided to the Company by registered mail addressed to the correct registered Company offices. 12. No Sub-Agents on Workers Compensation Business. Agent hereby agrees not to place or attempt to place business, other than non-subscription business, from any other agent not regularly affiliated with Agent as either an employee or an independent contractor of Agent, without the express written consent of Company. Should Agent bind a policy, except for non-subscription business, from a prohibited sub-agent without the express written consent of Company, Agent shall be fully responsible for all premiums due on policies that have been written for a sub-agent. This shall include all audit premiums, for which Agent agrees to pay Company directly without the ability to turn back such audit. 13. Underwriting Files. Agent agrees to provide the Company with complete copies of any underwriting file relating to business produced through the Company upon request by the Company for any reason whatsoever. 14. Electronic Signature Authorization. Agent hereby authorizes Company to accept electronic submission and bind requesting authority to occur securely over the internet via Company s web site. Under the Federal Electronic Signatures in Global and National Commerce Act (15 USCA , Company is able to accept and record acceptance electronically of agreements or contractual provisions. Agent pre-authorizes its employees to approve transactions stored on magnetic media within this agreement. Company shall still require that Agent obtain and make available upon request a physical signed application from the insured in order to bind any coverage. When Agent electronically requests a binder, Agent implies possession of a signed application completed by the insured and the Agent. Should Agent fail to produce such application signed by the insured and such failure create additional liability for either Copyright 2008 Combined Group Insurance Services, Inc. Page 2 of 6 Version 2.03 H2115

5 Company or any Carrier, Agent agrees to defend, indemnify, and hold Company and/or Carrier harmless for any damages, costs, penalties, fines, additional premiums, etc. arising out of such failure. Agent shall submit a signed application to Company on any policy when so required by Company in its sole discretion, either prior to or after the date of this Agreement. 15. Termination. The Company may terminate this Agreement immediately for Cause, which term shall be defined as theft, embezzlement, fraud, termination of Agent s license or a material breach of the Texas Insurance Code, or the breach of any provision of this Agreement that specifies such immediate termination. This Agreement may be terminated by either party at any time upon the giving of ten (10) days written notice to the other. If cancellation is either for Cause or at Agent's request, Agent must pay immediately all monies due to the Company in addition to giving required written notice, and the provisions of Section 5 above regarding return commissions shall remain in effect thereafter. If cancellation is at the Company's request, any commission due Agent on policies bound prior to termination shall be due and payable to Agent subject to offset against any return commission or earned premium due by Agent to the Company or any insurer. Should this Agreement be cancelled by the Company for non-payment of premiums or other sums due the Company, the Agent hereby grants the Company a lien against all Agent s rights, title, and interest in and to Agent s records, policy expirations, renewals, and notes and accounts receivable for all business produced under this Agreement as security and collateral for all premiums and return commissions for which the Agent may be liable to the Company. If the Agent does not settle the open account in full within thirty (30) days of the date of termination of this Agreement, the Company may then dispose of these said assets at its discretion in order to reduce the Agent's debt. Should the Agent fulfill all terms and conditions of this Agreement and make just payment to the Company for all premiums due within thirty (30) days, this assignment shall terminate and title to the records, policy expirations, renewals, and notes and accounts receivable shall revert to and become property of the Agent. If the Company shall dispose of Agent s assets in a commercially reasonably manner at a price insufficient to pay (i) all costs and expenses of disposition of Agent s assets, and (ii) all premiums, taxes, fees, and return commissions due Company upon termination of this Agreement, the Company shall further have the right to collect any shortfall from the Agent by any manner available to the Company at law or in equity. 16. Advertising. The Agent shall not employ the Company's name, nor that of any of the insurers or reinsurers with which it does business, or in any form of advertising without the prior express written authorization of the Company. 17. Assignment. The Agent shall not attempt to assign this Agreement in any respect without the prior written consent of the Company. Any potential sale of the Agent's business must be reviewed and approved by the Company before said sale shall be deemed effective as regards Agent's liability to the Company for premium or other sums due to the Company. Agent agrees that should Agent attempt to assign this Agreement without the prior written consent of the Company, the Agent s principals shall be jointly and severally liable personally for all premiums, fees, taxes, and other sums due under this Agreement prior to the sale. Should the Agent s buyers continue to do business with the Company after the sale without the knowledge of the Company, the Agent s principals shall be jointly and severally liable personally for all amounts accrued under this agreement until the Company is given actual knowledge of the sale. Once the Company is given actual notice of the sale, the Company may ratify the assignment of this Agreement in writing, at which time the original Agent shall be relieved of all responsibility for amounts due. 18. Audits. Unless otherwise determined by line of business, if premiums are shown to be owed by audit ("Audit ) on any policy, Agent must either remit payment for the Audit or return the Audit to the Company within forty-five (45) days after the Audit is transmitted to Agent. If Agent fails to return Audit to Company within forty-five (45) days of transmittal, Agent will be charged with and be responsible for remitting the premium, taxes, any fees owed to Company. If Agent does not return the Audit to the Company within the allotted forty-five (45) days after transmittal, the Company may withdraw the full amount of the audit, less commissions, by Electronic Funds Transfer at any time thereafter. If Agent returns the Audit to Company, Agent will no longer be responsible for payment of premium, taxes and fees owed on the Audit, nor will Agent receive commission on any portion of the premium subsequently collected by Company on the Audit. 19. Authorization to Investigate Agent s Credit. The Agent agrees to the Company's procuring, or causing to be procured, an "Investigative Consumer Report", and/or a "Credit Bureau Report", as the Company determines necessary, in connection with this Agreement. It is understood that the Agent may, within a reasonable time, make a written request to receive detailed information as to the nature and scope of said investigation. 20. Entirety. This Agreement supersedes all previous agreements, oral or written, between the Company and the Agent. 21. Choice of Law; Venue. Agent agrees that all provisions of this Agreement are performable in Dallas, Texas and agrees that the venue for any legal action shall be in Dallas County, Texas under the laws of the State of Texas. 22. Authority to Bind Agent. The signing principal(s) hereby affirms that he/she (they) has (have) the authority to bind the Agent by his/her (their) signature(s) to the terms and conditions of the Agreement, and further that he/she (they) also agree(s) to be bound by all said terms and conditions as an individual(s). Copyright 2008 Combined Group Insurance Services, Inc. Page 3 of 6 Version 2.03 H2115

6 This Agreement is executed in Dallas, Texas this day of Month of Year of and is hereby effective and shall automatically renew annually from the above date forward. COMPANY: Combined Group Insurance Services, Inc. Signed: Blake Stock Name in Full: CEO Title: Dated: AGENT: Signed: Name in Full: Title: Dated: Copyright 2008 Combined Group Insurance Services, Inc. Page 4 of 6 Version 2.03 H2115

7 EXHIBIT A SMALL BUSINESS AND MIDDLE MARKET PROGRAMS Company may enter into one or more Small Business or Middle Market Programs with various insurance companies. Agent is required to review and execute this Agreement in order for Agent to place business in any of these Programs. 1. Services Through Small Business and Middle Market Programs. Company may enter into agreements with various insurance carriers ( Carrier ) who handle small business and middle market accounts on a direct basis ( Small Business Programs and Middle Market Programs ). All accounts quoted by Company to Agent shall identify whether the account is being quoted through a Small Business or Middle Market Program. Agent acknowledges that the definition of a Small Business or Middle Market Program may vary considerably depending on the Carrier. Agent acknowledges that in the event Agent accepts a quote through Company in a Small Business or Middle Market Program, the following services may be provided by Company and/or the Carrier directly to Agent s customers through Carrier s Service Center: a. Direct billing of policy premiums and handling of inquiries thereof; b. Processing of policy renewals or changes; c. Processing of cancellation requests; d. Coverage counseling; and e. Other such commercial insurance services typically furnished by Agent other than new business solicitation. 2. Documentation of Services Provided. Company agrees to provide Agent at agreed upon intervals, either directly or through Carrier, with a listing of service transactions performed for Agent s Small Business and Middle Market Program customers including, but not limited to, cancellations, policy changes and renewals. 3. Risks Not Meeting Underwriting Standards for Small Business Programs. Should Agent place an account in a Carrier s Small Business Program, Carrier may, upon submission of the necessary underwriting information, be willing to quote and write ancillary lines of coverage that do not meet the criteria for Carrier s Small Business Program. Any risk placed by Agent in a Carrier s Small Business Program for which ancillary business does not meet said Carrier s Small Business Program underwriting standards solely based on the size of its exposure base may be referred to Carrier s regular commercial lines department for evaluation and potential quotation. Neither Company nor Carrier is obligated to quote or write such ancillary business and may decline to do so for any reason whatsoever. 4. Renewal of Small Business Program Risks. Any coverage sold on a Small Business Program basis shall be renewed on a Small Business Program basis if, in the sound underwriting judgment and sole discretion of the Carrier s underwriter, the risk remains an acceptable risk to the Carrier on a Small Business Program basis. Should the risk remain acceptable from an underwriting standpoint but fail to qualify for the Carrier s Small Business Program for whatever reason, the Carrier reserves the right to refer said business to Carrier s regular commercial lines department for evaluation and potential quotation. 5. Notice of Cancellation. Company shall give notification to the Agent of the non-renewal or cancellation of any Small Business or Middle Market Program coverage subject to this Exhibit A prior to such notice being mailed or delivered to the insured. 6. Direct Billing. All coverage placed in a Carrier s Small Business or Middle Market Program shall be payable on a direct billed basis. Agent shall be notified of transactions other than the placement of new business through reports from Company or Carrier. However, Company reserves the right, in its sole discretion, to bill certain policies or programs on either an account current basis or a cash-with-application basis. Such election will either be so stated on the quotation or, if the election is made after the quotation is received by the agent but prior to binding coverage, in a separate written communication to Agent. 7. Commission. Agent s commission will vary based on the line of business written as well as the Carrier writing the risk. The actual commission for new business will be indicated on each quote. Agent shall receive the same percentage commission on the renewal of pre-existing business unless either Company or Carrier shall notify Agent prior to binding said coverage. 8. Ownership of Expirations. Notwithstanding the servicing and/or referral of Agent s Small Business or Middle Market customer existing business, Agent shall maintain exclusive ownership of the expirations and renewals associated with Agent s Small Business and Middle Market Program customer s business. Neither Company nor Carrier shall use their books or records of such customers and business to place or renew coverage for such customers or policyholders in any way which deprives or interferes with Agent s rights to ownership or to any commissions with respect thereto, nor shall Company refer or disclose such customers or policyholders information contained in it s book and records to any third party competitor of Agent without the express written consent of Agent. Copyright 2008 Combined Group Insurance Services, Inc. Page 5 of 6 Version 2.03 H2115

8 9. Agent s Freedom to Market Coverage. Nothing contained herein shall operate to prohibit Agent from canceling any policy of insurance with Carrier in any Small Business or Middle Market Program upon proper authorization from the insured. Further, nothing contained herein shall prohibit Agent from marketing any insured s coverage upon expiration of any policy with Carrier and replacing the Coverage expiring with Carrier with any other insurer. 10. Termination of Agent s Agreement. Upon termination of Agent s entire Agency Agreement with Company or this Addendum, Agent may elect to continue having Company perform such services as were performed immediately prior to such termination or expiration of any account covered by this Addendum for the one (1) year period immediately following such termination or expiration effective date. Agent must so elect in writing to Company within thirty (30) days after the termination or expiration of this Addendum takes effect. Upon the conclusion of said one (1) year period, Company shall be entitled to transfer all servicing of such accounts back to Agent. Company shall not be required to provide such agency services if such action is prohibited by law or the order, rule, or regulation of a regulatory official or if Company is prohibited from doing so by the Carrier. Copyright 2008 Combined Group Insurance Services, Inc. Page 6 of 6 Version 2.03 H2115

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10 Address Form: *Please print clearly *Please include first and last name *Please list only those employees you wish to receive marketing correspondence from Combined Group. Principal(s): Staff: Preston Rd., #350 Dallas, TX Phone: Fax: Toll Free: Fax:

11 PayExpress Authorization Form What is Electronic Funds Transfer (EFT)? EFT is a debit service that offers you a convenient way to pay your insurance premiums online from your bank account. Withdrawals will appear on your bank statement. In order to activate this service you must: Completely fill out this form Include a copy of a voided check or deposit slip for the account you wish to use Sign and date the form (signer must be an authorized signer on the account) Fax or form and copy of check/deposit slip to: Bobbie Hayes Fax #: bhayes@combinedgroup.com Phone: Electronic Funds Transfer (EFT) Authorization: I the undersigned account holder, authorize Combined Group Insurance Services Inc. to electronically withdraw money from my account at: Name of bank: Bank address: Bank Routing # Bank Account # Type of account: Checking Savings for the payment of premiums and other charges on my statement of account as I designate through PayExpress. I will compensate Combined Group for any loss, claim, or liability caused by these withdrawals and will hold Combined Group harmless for any such loss, claim, or liability that may be claimed by any financial institution or third party including NSF fees. This authorization will not affect the terms of the policy(ies) shown on my statement of account. If the premiums are not paid within the grace period allowed, the policy(ies) will be subject to cancellation. If Combined Group s internet site or the PayExpress feature is inoperative, I agree, on the day my premiums are due, to immediately write a check to Combined Group and mail it to be postmarked on the day premiums are due. This authorization may be retracted by myself or Combined Group at any time for any reason by written notice. Signature of Accountholder: Date: Printed name of signer: *DON T FORGET TO INCLUDE YOUR COPY OF A VOIDED CHECK OR DEPOSIT SLIP!*

12 Authorization for Direct Deposit (EFT) of Commissions, Premium Refunds, Overpayments, Etc. Agency Name: Bank Name: Bank City, State: Bank 9 Digit Routing #: Name on the Account: Bank Account Number:, I hereby authorize Combined Group Insurance Services, Inc. to deposit my commissions, premium refunds, overpayments, etc. into my account at the bank designated above. Depositor Signature: Date: Printed Name: Daytime Phone #: Attach copy of voided check here or preprinted deposit slip (if the routing # is the same) Please note that a valid ABA routing # will only start with a 0, 1, 2, or 3. (checking accounts only)

13 Agent Direct Express Signup For fast setup, to or fax to Agency Account Owner Title Phone Number Additional Users Account Information Payment Information (Credit Card or Check Draft) Option 1: Credit Card (check one) MasterCard Visa Credit Card Number Expiration Date CVV (on back of Card) Option 2: Check Draft Routing Number Account Number Name (on account) First Name Last Name Address Address Phone Sales Representative Carrier Setup Important: User name & passwords are case sensitive. User # First & Last Name Carrier User Name (case sensitive) Password (case sensitive) Producer Code #1 Allied #1 CNA #1 Hartford #1 Safeco #1 Travelers #1 Zurich #1 Liberty RAM (America First, Golden Eagle, etc.) #2 Allied #2 CNA #2 Hartford #2 Safeco #2 Travelers #2 Zurich #2 Liberty RAM (America First, Golden Eagle, etc.) #3 Allied #3 CNA #3 Hartford #3 Safeco #3 Travelers #3 Zurich #3 Liberty RAM (America First, Golden Eagle, etc.)