Documentation Checklist

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Roberta Walters
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Documentation Checklist Agent Name: Submit Date: Agent Support Specialist: Upline Name: PRODUCER INFORMATION SHEET Social Security number, date of birth, license information, contact number, current

1 Documentation Checklist Agent Name: Submit Date: Agent Support Specialist: Upline Name: PRODUCER INFORMATION SHEET Social Security number, date of birth, license information, contact number, current address and mailing address must be accurate and legible. List E&O carrier and expiration date (REQUIRED) Provide written explanation for any YES on the background questions. Please include accurate incident dates, supporting documents and a handwritten signature. DIRECT DEPOSIT FORM Handwritten signature for authorization of ACH. Include voided check. If one is not institution. available, provide a deposit ticket or letter from financial All information on direct deposit form must be clearly written and legible. W-9 Name on W-9 MUST match all other documents. If you do not have a Tax ID, you may use your social security number only if your name is listed in Line 1 of form and the name of the agency/corporation is listed on Line 2. REQUIRED DOCUMENTS Verified Scanned Updated In FMP Current, Unexpired E&O certificate. Must maintain coverage at all times. Valid, unexpired insurance license for each state broker is licensed in. Team Alvarez Code of Ethics. Must have a handwritten signature to be valid. Producer information filled out as described above. Direct deposit Form Filled out as described above. Voided check (preferred), deposit form or letter from financial institution validating account Written explanation on separate page for any YES answer on background questions ***For Office Use Only*** Agent ID Attached to Agent Record Ready To Shred

2 Producer Information Sheet SECTION 1 - AGENT INFORMATION AGENT NAME: DATE OF BIRTH: SOCIAL SECURITY NUMBER: TAXPAYER ID NUMBER: PLEASE INITIAL THE APPROPRIATE BOX BELOW Individual Corporation Partnership Other HOME ADDRESS: CITY: STATE: ZIP CODE: MAILING ADDRESS: CITY: STATE: ZIP CODE: HOME OFFICE: CELL PHONE: OFFICE PHONE: FAX NUMBER: SECTION 2 - BACKGROUND INFORMATION Have you ever had your insurance license suspended or revoked? YES NO Is your insurance license currently restricted or under investigation? YES NO Have you ever been refused a surety bond or had a claim paid for you? YES NO Have you ever filed for bankruptcy? YES NO Have you ever been convicted of a felony or misdemeanor, excluding traffic violations? YES NO Are you at present involved in any litigation or administrative proceeding related to the insurance business, OR, are there any unsatisfied judgments against you? Have you ever been listed as debarred, excluded or otherwise ineligible for participation in Federal Healthcare Programs? Are you currently listed with Vector One? YES NO If YES, Please complete the following: Company Owed: Company Owed: Balance: Balance: IF YOU ANSWER YES TO ANY OF THE ABOVE, YOU MUST SUBMIT A WRITTEN EXPLANATION ALONG WITH SUPPORTING DOCUMENTATION DETAILING THE EVENTS IN ORDER TO BE CONSIDERED FOR APPOINTMENT YES YES NO NO SECTION 3 - LICENSING INFORMATION RESIDENT STATE: LICENSE NUMBER: EXPIRES: STATE: LICENSE NUMBER: EXPIRES: STATE: LICENSE NUMBER: EXPIRES: STATE: LICENSE NUMBER: EXPIRES: ERRORS AND OMISSIONS (E&O) INFORMATION CARRIER: POLICY #: EXPIRES:

3 Direct Deposit Authorization Team Alvarez Insurance Services (herein referred to as Team Alvarez ) is pleased to provide direct deposit of your commissions into your bank account. Here are some of the benefits you will receive with our direct deposit program: Get your commission payments fast. Funds are deposited three working days after Team Alvarez transmits to the bank. No more lost checks. No more trips to the bank to deposit checks. Your statement, which will be ed to you, will indicate the amount of the deposit. The authorization form below states that we may make debit entries to your account ONLY in the rare case of a bank error or a commission processing error. We will NOT deduct debit balance from your bank account. In order to begin direct deposit, please complete the following authorization form below. Please be sure to sign the form and attach a voided check or savings deposit slip. If you change your bank account number, please notify us immediately to avoid delays in your commission. A written request along with a new voided check or deposit slip must be submitted in order to change this information. NAME: DATE: SOCIAL SECURITY NUMBER: TAXPAYER ID: ADDRESS: I authorize Team Alvarez Insurance Services to initiate electronic credit entries for commissions due. Debit entries will ONLY be made in the rare case of an error by either the bank or Team Alvarez to correct a credit entry previously made or a commission processing error. As of (Date), Deposits shall be made to the following account: CHECKING Routing #: Account #: SAVINGS Routing #: Account#: FINANCIAL INSTITUTION: CITY: STATE: ZIP CODE: SIGNATURE: DATE:

4 Please Attach Voided Check Or Deposit Ticket Here

9 Team Alvarez Code of Ethics This Code of Ethics was developed to ensure that Team Alvarez Agents soliciting applications for any insurance product have a clear understanding of their moral and ethical responsibilities during every interaction with customers. No statement of policy can be so comprehensive that it covers all possible situations. For this reason, agents must exercise professional judgment with respect to each work situation that arises and seek advice from upline management when uncertainty or difficult questions remain. Agents are expected to comply with both the written and the spirit of this Code of Ethics. Violations of this Code of Ethics may be grounds for disciplinary action, including immediate dismissal and termination of the Agent s rights to solicit applications on behalf of Team Alvarez. Principles: An Agent shall... Approach every interaction with integrity To have integrity is to be fair, objective, and straightforward in all interactions. You are open, honest, and truthful; there are no hidden motives or secret agendas. Put customers first A customer-first philosophy is a guiding principle that should influence every decision you make. This philosophy may lead you to suggest that a customer takes a few days to review materials before arriving at a decision. Be an expert and stay informed You are knowledgeable about every product you sell and how different products meet different needs. You explain the benefits of products in plain language and appropriate detail so that customers completely understand each product. You display a continuous commitment to lifelong learning and professional improvement.

10 Sales Practice Guidelines Prohibited Marketing and Selling Behaviors 1. Activities which are discriminatory in nature or intended to discourage beneficiary enrollment on the basis of race, physical or mental ability, ethnicity, gender, sexual orientation, creed, age, religion or national origin, cultural educational background, economic or health status, English proficiency, reading skills, or source of payment of care. 2. Activities that mislead or confuse beneficiaries or which misrepresents Team Alvarez. Such activities may include, but are not limited to: (a) Claims of endorsement of the Company you are presenting by CMS or the United States Government. (b) Claims that CMS recommends the Product you are presenting. (c) Erroneous written or verbal statements, including statements, claims or promises that conflict with or materially alter information contained in CMS approved materials. (d) Offers of gifts or payments directly or indirectly to beneficiaries or any individual in a position to influence enrollment as an inducement to enroll on the plan being presented. (e) Door-to-door solicitation. (f) Altering or amending, in any fashion, any Company approved materials. (g) Engaging in health screenings of prospective members or in activities which could reasonably be construed to be health screening. (h) Submitting fraudulent enrollment forms, or forging any enrollment form or supporting documentation. (i) Distributing materials or soliciting enrollment at any healthcare delivery site while care is being delivered. (j) Soliciting any endorsements or patient lists from any health providers. (k) Selling leads. (l) Soliciting any enrollments from beneficiaries; incompetent to complete and understand the Statement of Understanding from the enrollment form. Individuals clearly incompetent shall only be enrolled when accompanied by appropriate representation. (m) Engaging in any bait and switch activities or other fraudulent behaviors, including, but not limited to: overselling, churning, and sliding unnecessary additional policies. (n) Engaging in aggressive selling techniques or ignoring customer needs.

I am committed to maintaining Team Alvarez reputation as a quality and reputable insurance agency.

11 3. Agents will understand a customer s unique needs and only sell a product if it fits their needs. 4. Agent will make a best effort to ensure that all customers fully understand their options and the features of the products they purchase. I am committed to maintaining Team Alvarez reputation as a quality and reputable insurance agency. I clearly understand the above statements and accept this Code of Ethics as my standard for conducting business while representing Team Alvarez. Sales Representative/Broker Printed Name: Signature: Date: Team Alvarez Insurance Services 201 S. Anita Drive, Ste. 203 Orange, CA Phone: (714) Fax: (805)

AMENDED AARP PROGRAM AGENCY ADDENDUM

AMENDED AARP PROGRAM AGENCY ADDENDUM This Amended AARP Program Agency Addendum ( Addendum ) amends and restates the AARP Program Agency Addendum to the Agency Agreement (together with all amendments and