Stonebridge Life Insurance Company

Transcription

1 PRODUCER APPOINTMENT APPLICATION I am requesting an appintment and agreement with the belw cmpany(ies) (each individually referred t as the Cmpany ). Stnebridge Life Insurance Cmpany PERSONAL DATA FIRST: MIDDLE: LAST: SUFFIX: SOCIAL SECURITY NUMBER: DATE OF BIRTH: GENDER: PRIMARY TELEPHONE: SECONDARY TELEPHONE: FAX #: FINRA REGISTERED? IF YES, BROKER-DEALER NAME: ADDRESS: HOME ADDRESS (Mandatry fr backgrund investigative reprt requirements.) STREET: APT#: CITY: STATE: ZIP: COUNTRY: BUSINESS ENTITY NAME IF APPLICABLE: BUSINESS ADDRESS (if different than Hme Address) STREET: STE#: P.O. BOX: CITY: STATE: ZIP: COUNTRY: APPOINTMENT INFORMATION NON-RESIDENT APPOINTMENTS DESIRED: FLORIDA COUNTIES DESIRED: LPAA4112 L&P PAA Paper App Page 1 f 4

2 BACKGROUND INFORMATION Yes N A. Have yu been cnvicted f, r pled guilty r nl cntendere ( n cntest ) t a felny r misdemeanr invlving: insurance, investments r a related business, fraud, false statements r missins, wrngful taking f prperty, r bribery, frgery, cunterfeiting r extrtin, r breach f trust? If yes, prvide explanatin belw and attach supprting curt dcumentatin. B. Have yu ever been cnvicted f, r pled guilty r nl cntendere ( n cntest ) t any ther felny r misdemeanr? If yes, prvide explanatin belw (including date, cunty, and state in which the felny r misdemeanr ccurred) and attach supprting curt dcumentatin. C. Has any State Insurance Department r ther State r Federal Regulatry Agency ever denied, suspended r revked yur license r registratin? If yes, prvide explanatin belw and attach supprting dcumentatin. D. Have yu persnally r a firm that yu exercised management cntrl ver, r wned 10% r mre f the securities f, failed in business, made a cmprmise with creditrs, filed a bankruptcy petitin r been declared bankrupt? If yes, prvide explanatin belw and attach supprting dcumentatin, fr example, a cpy f riginal filing, discharge, and Schedule F. E. D yu have any utstanding r unsatisfied cllectins, judgments and/r liens, including tax liens, ttaling $50,000 r mre? If yes, prvide explanatin belw and attach supprting dcumentatin, fr example, a cpy f IRS repayment schedule, etc. F. Has any State Insurance Department, any ther State r Federal Regulatry Agency, r the SEC, FINRA r any ther Self Regulatry Organizatin ever entered an rder against yu relative t a vilatin f insurance r investment-related regulatins r statutes? If yes, prvide explanatin belw and attach supprting dcumentatin. G. D yu currently have an utstanding debit balance with any ther insurance carrier(s), insurance agency, r brker-dealer? If yes, prvide explanatin belw. LPAA4112 L&P PAA Paper App Page 2 f 4

3 BUSINESS ENTITY INFORMATION If applicant is a crpratin, partnership, r LLC and fixed prduct cmmissins r cmpensatin are t be disbursed t the entity, please cmplete the fllwing: LEGAL NAME OF ENTITY TIN FOR ENTITY ERRORS AND OMISSIONS Are yu cvered by an Errrs and Omissins plicy? If s, attach E & O certificatin. DIRECT DEPOSIT NAME OF BANK: ROUTING NUMBER: BANK PHONE NUMBER: DEPOSITORY NAME: ACCOUNT NUMBER: ACCOUNT TYPE: FIRST NAME: RECRUITER INFORMATION (If knwn) LAST NAME: ADDRESS: ADDITIONAL INFORMATION LPAA4112 L&P PAA Paper App Page 3 f 4

4 CERTIFICATION I certify that the infrmatin cntained in this applicatin is true and cmplete t the best f my knwledge and belief. I have received the Fair Credit Reprting Act Disclsure and Authrizatin f Cnsumer Reprt/Investigative Cnsumer Reprt and A Summary f Yur Rights Under the Fair Credit Reprting Act. If I have been ntified by the IRS that I have previusly given an incrrect taxpayer identificatin number, my signature belw cnstitutes my certificatin under penalties f perjury t the fllwing: (1) the taxpayer identificatin number n this frm is my crrect taxpayer identificatin number; and (2) I am nt subject t backup withhlding; and (3) I am a U.S. persn (including a U.S. resident alien). I acknwledge that the IRS des nt require my cnsent t any prvisin f this frm ther than the certificatin required t avid backup withhlding. I acknwledge receipt f the 1994 Crime Act Ntice, and I certify that I am nt in vilatin f the prvisins f the 1994 Crime Act described in that ntice. I have received and will cmply with the Cmpany s Cde f Prfessinal Cnduct fr prducers and emplyees. I agree t update any changes t the respnses prvided in this applicatin t Questins (A) thrugh (G) under the Backgrund Infrmatin sectin within 5 days f such change. ACKNOWLEDGEMENT If I am appinted with mre than ne Cmpany, I acknwledge and agree that the Prducer Agreement r ther agreement evidencing such appintment is t be cnstrued as cnstituting separate and distinct agreements between me and each Cmpany with which I am appinted. The rights, bligatins, and respnsibilities between me and ne Cmpany are separate and distinct frm the rights, bligatins, and respnsibilities between me and any ther Cmpany with whm I may be appinted. N Cmpany will have respnsibility r liability fr the acts r missins f any ther Cmpany with whm I may be appinted. AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authrize any emplyer, insurance cmpany, managing agent, educatinal institutin, financial institutin, cnsumer reprting agency, criminal justice agency, insurance department r individual having any infrmatin relating t my activities t release such infrmatin t the Cmpany, r any affiliated cmpany, r any cnsumer reprting agency acting fr and n behalf f the Cmpany r fr and n behalf f any ther affiliated cmpany. This infrmatin may include, but is nt limited t, emplyment and jb perfrmance histry, academic recrds, credit recrds, disciplinary, arrest and cnvictin recrds, and persnal histry, including infrmatin as t character, general reputatin and mde f living. Signature (Full Name) (Printed Name) (Date) LPAA4112 L&P PAA Paper App Page 4 f 4

5 LPCAH4112 L&P PCA HIPAA PRODUCER S CONDITIONAL AGREEMENT As an agent wh has been appinted with Mnumental Life Insurance Cmpany, Stnebridge Life Insurance Cmpany, Transamerica Financial Life Insurance Cmpany, Transamerica Life Insurance Cmpany, and/r Western Reserve Life Assurance C. f Ohi (each individually referred t as the Cmpany ), I acknwledge and agree that if I am appinted with mre than ne Cmpany, the Prducer s Cnditinal Agreement r ther agreement evidencing such appintment is t be cnstrued as cnstituting separate and distinct agreements between me and each Cmpany with which I am appinted. The bligatins and respnsibilities between me and ne Cmpany are separate and distinct frm the bligatins and respnsibilities between me and any ther Cmpany with whm I may be appinted. N Cmpany will have respnsibility r liability fr the acts r missins f any ther Cmpany with whm I may be appinted. I further have agreed t the fllwing: a. Unless I hld a persnal cntract with the Cmpany which gvern(s) fixed insurance prducts, the Cmpany has n bligatin t pay me cmmissins r any frm f cmpensatin whatsever in cnnectin with the services perfrmed and expenses incurred by me in the slicitatin f applicatins fr insurance prducts issued by the Cmpany, it being expressly understd that I will be cmpensated pursuant t a separate agreement between me and my current Brker- Dealer r Agency and I will have n right, remedy, r recurse against the Cmpany fr any cmpensatin. Unless therwise ntified by the Cmpany in writing, this Agreement will remain in effect upn my transfer t anther Brker-Dealer r Agency having a Selling Agreement in effect with the Cmpany, prvided my appintment with the Cmpany has nt been terminated. The understandings in this paragraph will nt apply t the sale f any prducts fr which I have entered int a separate agreement with the Cmpany. b. I understand that n cmmissins are payable n a plicy which replaces, exchanges, r terminates anther plicy f the Cmpany r any f its affiliates unless such replacement is accmplished in accrdance with the Cmpany rules in frce at that time. c. I will cmply with all applicable laws and regulatins f the states in which I sell prducts including, but nt limited t, btaining and maintaining any necessary licenses fr the slicitatin f insurance. d. I will nt alter, mdify, waive r change any f the terms, rates r cnditins f any advertisements, receipts, plicies r cntracts f the Cmpany in any respect. I will nt use any advertising r sales material relating directly r indirectly t the Cmpany r the Cmpany s prducts unless it is prvided by the Cmpany r apprved by the Cmpany in writing prir t use. e. I will deliver any plicy sent t me within thirty (30) days frm the pstmark date such plicy is mailed by the Cmpany. f. I will prmptly remit t the Cmpany any and all mnies received by me n behalf f the Cmpany as payments n life insurance plicies, and I have n right r authrity t receive r cllect mnies fr and n behalf f the Cmpany at any time r fr any purpse except the initial premium necessary t put the insurance plicy in frce. All mnies r securities received by me as full r partial payment f premiums r fr any ther item withut exceptin, shall be held by me in trust separate frm my wn r ther funds and will be immediately delivered and paid t the Cmpany. g. The Cmpany may, with r withut cause and withut liability t me whatsever, cancel my appintment at any time, and upn terminatin f this Agreement I will immediately deliver t the Cmpany all recrds, sales and advertising material, statinery, business cards, cmputer sftware and ther supplies cnnected with the Cmpany s business. h. I will cmply with the Cmpany s Cde f Prfessinal Cnduct fr Prducers and Emplyees as it may be amended frm time t time. I understand and agree t the fllwing plicies. i. I will cmply with all applicable laws and regulatins t prtect the privacy f nnpublic infrmatin that I have abut an applicant, wner, insured, beneficiary, r ther persn wh seeks t btain, btains r has btained a prduct r service frm the Cmpany. If I receive such nnpublic infrmatin frm the Cmpany, I will maintain the cnfidentiality f such infrmatin and understand that I am prhibited frm using such infrmatin ther than t carry ut the purpse fr which such infrmatin was disclsed t me. I agree t take reasnable measures t secure and safeguard such nnpublic infrmatin in my pssessin (including apprpriate destructin and dispsal methds). I als agree t ntify the Cmpany within 48 hurs upn learning f an actual r ptential breach invlving the privacy r security f any nnpublic client infrmatin in my pssessin, r in the pssessin f my emplyee, agent, representative, r vendr/subcntractr. j. I will cmply with the Cmpany s rules fr electrnic imaging and transmissin f dcuments. k. I will cmply with the Cmpany s anti-mney laundering plicies and reprting requirements and understand that failure t cmply may result in terminatin f my appintment. l. I will cmply with all applicable laws, regulatins and cmpany plicies pertaining t requirements that prducts be suitable fr the purchaser.

6 7.1 Privacy and Cnfidentiality Generally m. Except t the extent directly required t perfrm yur services under this Agreement, yu shall hld in strictest cnfidence and nt disclse t any Persn r use, at any time, whether during r after the terminatin f this Agreement, any infrmatin that we disclse r make available t yu that is cnfidential r prprietary ( Infrmatin ). Withut limiting yur bligatins under the previus sentence, yu shall apply at least the same standard f care t prtect the cnfidentiality f the Infrmatin as yu use t prtect yur wn cnfidential infrmatin. Upn terminatin f this Agreement, yu shall return r securely destry all Infrmatin withut retaining any cpies and shall prvide us with yur written and signed certificatin t that effect. All Infrmatin is ur sle and exclusive prperty. n. If yu are requested t disclse Infrmatin pursuant t a subpena r rder frm a gvernmental authrity (including any department f insurance), yu shall (A) ntify us as prmptly as pssible, and in any event prir t respnding theret, f the terms f and circumstances relating t such request, (B) cnsult with us n the advisability f attempting t resist r narrw such request, and (C) if disclsure f Infrmatin is required, furnish nly such Infrmatin as ur cunsel advises us yu are legally bligated t disclse and cperate with us t btain assurance that the disclsed Infrmatin will be held in cnfidence. Yu als shall cmply with ur privacy and security rules that we have prvided t yu in writing. 7.2 Cmpliance with GLBA Yu shall cmply with the privacy requirements f the Gramm-Leach-Bliley Act and its rules and regulatins as any f the same may be amended r superseded frm time t time ( GLBA ). Cmpliance with GLBA includes the fllwing: a. Yu may use r disclse Nnpublic Persnal Financial Infrmatin nly t perfrm yur services under this Agreement, as specifically prvided in Sectin 7.6(c) belw, r as required by law. Nnpublic Persnal Financial Infrmatin means persnally identifiable financial infrmatin and includes any list, descriptin, r ther gruping f cnsumers (and publicly available infrmatin pertaining t them) that is derived using any nnpublic persnal infrmatin; prvided, hwever, that the abve definitin shall be superseded and replaced t the extent that the definitin f Nnpublic Persnal Financial Infrmatin under Title V f Public Law , Sectin 509, subsectin (4), as the same may be amended r superseded frm time t time, differs frm this definitin. b. Yu shall maintain apprpriate administrative, physical and technical safeguards t prevent prhibited uses r disclsures f Nnpublic Persnal Financial Infrmatin. c. Yu shall require that yur sub-agents, directrs, fficers, and emplyees wh have access t Nnpublic Persnal Financial Infrmatin agree in writing t the same restrictins and cnditins that apply t yu. 7.3 ACE Designatin under HIPAA Yu acknwledge that the health care cmpnents f the Cmpanies (such health care cmpnents cllectively, the Cvered Entity ), have elected t adpt Affiliated Cvered Entity ( ACE ) status, as defined and permitted under the Health Insurance Prtability and Accuntability Act f 1996 and its rules and regulatins as any f the same may be amended r superseded frm time t time ( HIPAA ), such designatin has been apprpriately adpted and dcumented, and any Cmpany is authrized t enter int a Business Assciates Agreement n behalf f sme r all ther members f such ACE. T the extent the HIPAA cvered health care cmpnent f any such member f the ACE merges with anther affiliate r underges a crprate name change, this Agreement shall apply t any such merged and/r renamed cmpnent/cmpany. 7.4 Cmpliance with HIPAA Yu shall cmply with the privacy and security requirements f HIPAA. Cmpliance with HIPAA includes the fllwing: a. Yu may use r disclse Prtected Health Infrmatin nly t perfrm yur services under this Agreement, fr the prper management and administratin f yur business (ther than fr crss-marketing and/r crss-selling f ther plicies r prducts, which are prhibited except t the extent specifically prvided in Sectin 7.6(c) belw), t carry ut yur legal respnsibilities, r therwise as required by law. Prtected Health Infrmatin has the same meaning as the term prtected health infrmatin in 45 C.F.R (as the same may be amended r superseded frm time t time), limited t infrmatin that yu create r that yu receive frm us r n ur behalf, and includes infrmatin that relates t the past, present, r future physical r mental health r cnditin f a Plicyhlder, t the prvisin f health care t a Plicyhlder, r t the past, present, r future payment fr the prvisin f health care t a Plicyhlder, and that identifies the Plicyhlder r fr which there is a reasnable basis t believe that the infrmatin can be used t identify the Plicyhlder, in each case regardless f whether the Plicyhlder is living r deceased. By way f illustratin nly, the fllwing infrmatin shall cnstitute Prtected Health Infrmatin with respect t a Plicyhlder: (A) name, (B) street address, city, cunty, precinct, and zip cde, (C) dates directly related t the Plicyhlder, including birth date, admissin date, discharge date, and date f death, (D) telephne numbers, fax numbers, and electrnic mail addresses, (E) scial security number, (F) medical recrd numbers, (G) health plan beneficiary numbers, (H) accunt numbers, (I) certificate/license numbers, (J) vehicle identifiers and serial numbers, including license plate numbers, and (K) any ther unique identifying numbers, characteristics, r cdes. LPCAH4112 L&P PCA HIPAA

7 b. Yu may nt use r disclse Prtected Health Infrmatin in any manner that wuld cnstitute a vilatin f 45 C.F.R. Parts 160 and 164 if we used r disclsed the infrmatin in the same manner. c. Yu shall cmply with ur request t accmmdate a Plicyhlder s access t his r her Prtected Health Infrmatin as prvided by 45 C.F.R d. Yu shall cmply with ur request t amend Prtected Health Infrmatin in accrdance with a Plicyhlder s request as prvided by 45 C.F.R e. Yu shall keep a recrd f disclsures f r access t Prtected Health Infrmatin that must be prvided under HIPAA t an individual t whm the Prtected Health Infrmatin relates. Yu shall cmply with any request that we make t prvide us with infrmatin pertaining t such disclsures r access in such frmat as we reasnably may request. Such prvided infrmatin shall include the cntent as required under HIPAA. f. Yu shall make yur internal practices, bks, and recrds relating t uses and disclsures f Prtected Health Infrmatin available t us (r t ur designee) and t the Secretary f the U.S. Department f Health and Human Services (the Secretary ), r t the Secretary s designee, fr the purpse f cnfirming yur cmpliance and/r ur cmpliance with 45 C.F.R. Parts 160 and 164. g. Upn terminatin f this Agreement, if feasible, yu shall return r destry all Prtected Health Infrmatin withut retaining any cpies and shall prvide us with yur written and signed certificatin t that effect. If such return r destructin is nt feasible, yu shall limit all further uses and disclsures t thse purpses that make such return r destructin f the Prtected Health Infrmatin nt feasible. h. Yu shall maintain apprpriate administrative, physical and technical safeguards t prevent prhibited uses r disclsures, and t prtect the cnfidentiality, integrity and availability, f any Prtected Health Infrmatin that yu create, receive, maintain r transmit. Such safeguards shall include develpment, implementatin, and maintenance f a cmprehensive written infrmatin security prgram cmpliant with applicable laws and designed t (A) prtect the integrity and cnfidentiality f Prtected Health Infrmatin, (B) prtect against anticipated threats r hazards t the security, cnfidentiality and/r integrity f Prtected Health Infrmatin, (C) prtect against any unauthrized disclsure r use f Prtected Health Infrmatin, (D) address cmputer and netwrk security, (E) address physical security, and (F) prvide fr the secure dispsal and destructin f Prtected Health Infrmatin. i. Yu shall ensure that any subcntractrs (as defined in 45 C.F.R ) that create, receive, maintain, r transmit Prtected Health Infrmatin n yur behalf agree t the same restrictins and cnditins that apply t yu with respect t such infrmatin. Yu agree t enter int apprpriate written agreements utlining these bligatins and t btain satisfactry assurances (as that term is cntemplated in HIPAA) f such cmpliance by all subcntractrs. T the extent yu make disclsures under 45 C.F.R (e)(4), yu will btain reasnable assurances that PHI will be held in cnfidence and will nt be used r disclsed utside f the intended purpse. j. T the extent that we may require yu t carry ut ACE Entities bligatins in accrdance with the Agreement, under 45 C.F.R. 164 Subpart E, yu will cmply with the requirements f that Subpart which apply t ACE Entities in the perfrmance f such bligatins. k. Yu shall require that yur directrs, fficers, and emplyees wh have access t Prtected Health Infrmatin agree t the same restrictins and cnditins that apply t yu with respect t such infrmatin. 7.5 Cmpliance with HITECH Act a. Yu agree and acknwledge that yu are directly subject t HIPAA as amended by the HITECH Act, including, withut limitatin, Sectins , , and theref, including its prvisins relating t security and privacy f Prtected Health Infrmatin as well as its enfrcement and penalty prvisins. Yu agree that yu will (A) cmply with all applicable security and privacy prvisins f HIPAA as amended by the HITECH Act and as it may be amended frm time t time; (B) nt act in any way t interfere with r hinder the ACE Entities ability t cmply with HIPAA as amended by the HITECH Act and as it may be amended frm time t time; and (C) use yur best effrts t ntify the ACE Entities withut unreasnable delay and in any event within three (3) business days f discvering a breach, as the term breach is defined in 45 C.F.R , and as the terms breach and discver are further described in 45 C.F.R (a)(2). b. In the event either party learns f a pattern f activity r practice f the ther party that cnstitutes a material breach r vilatin f its bligatins relating t Prtected Health Infrmatin under the Agreement, the nn-breaching party will take reasnable steps t cure the breach r end the vilatin. If such steps are unsuccessful, the nn-breaching party will terminate the Agreement, if feasible, r if terminatin is nt feasible, reprt the prblem t the Secretary. We reserve the right, in ur sle discretin, t terminate this Agreement immediately upn ntice in the event f any such material breach r security incident. LPCAH4112 L&P PCA HIPAA

8 c. Yu acknwledge and agree t adhere t any limitatins n the disclsure and/r sale f Prtected Health Infrmatin as required under 45 C.F.R (d) and/r under HIPAA. 7.6 Additinal Prvisins Relating t Cnfidentiality Generally, GLBA, and HIPAA a. In respnse t an unslicited direct Plicyhlder, Certificatehlder, r Cnsumer inquiry, yu may disclse Nnpublic Persnal Financial Infrmatin and Prtected Health Infrmatin directly t, and may discuss such infrmatin directly with, the Plicyhlder, Certificatehlder, r Cnsumer t whm such infrmatin pertains, prvided that such disclsure wuld nt vilate HIPAA if we made it. b. We acknwledge that yu may have relatinships with affinity grups and assciatins and that, as a result, yu may receive infrmatin ( Grup Member Infrmatin ) relating t their members (each a Grup Member ) that cnstitutes Nnpublic Persnal Financial Infrmatin and/r Prtected Health Infrmatin. Yu and we agree that a Grup Member s Grup Member Infrmatin shall cnstitute Nnpublic Persnal Financial Infrmatin and/r Prtected Health Infrmatin nly frm and after the time that a Grup Member applies fr a Plicy. c. Yu may use Infrmatin, Nnpublic Persnal Financial Infrmatin and/r Prtected Health Infrmatin fr crssmarketing and/r crss-selling f ther plicies r prducts t the extent, but nly t the extent, that the Plicyhlder t whm such infrmatin pertains has authrized yu specifically in a writing that cmplies with HIPAA t d s and such marketing and selling is cnducted in adherence with the restrictins n marketing and sale f PHI as prvided under HIPAA. d. Any ambiguity in this Agreement shall be reslved in favr f a meaning that permits cmpliance with GLBA and HIPAA. e. Yu shall ntify us in writing withut unreasnable delay and in any event within three (3) business days after becming aware f a vilatin f Sectins 7.2, 7.4, 7.5, r 7.6 f this Agreement, r f the ccurrence f a security incident, as defined in 45 C.F.R Yu agree t cperate fully with us in any security-incident investigatin r reslutin and agree that n ntificatins r cmmunicatins t any individual(s), media utlets, state r federal regulatry authrities, r ther third parties regarding the incident shall be made withut in each instance ur specific prir written cnsent. f. Yu shall cmply with all applicable state and lcal laws and regulatins enacted t prtect the privacy f individual persnal infrmatin. g. We can amend Sectins 7.2, 7.4, 7.5, r 7.6 f this Agreement withut yur cnsent t reflect (i) future amendments f GLBA r HIPAA, r (ii) curt rders interpreting the applicatin f GLBA r HIPAA, r (iii) a material change in ur business practices, but any such amendment shall be enfrceable against yu nly after we have ntified yu. Other principles and standards t use in daily cnduct can be fund in the Practical Guide t Prfessinal Cnduct. These plicies, prcedures and guidelines can be changed frm time t time. LPCAH4112 L&P PCA HIPAA

9 Mnumental Life Insurance Cmpany Stnebridge Life Insurance Cmpany Transamerica Financial Life Insurance Cmpany Transamerica Life Insurance Cmpany Western Reserve Life Assurance C. f Ohi Christpher Lintecum Vice President ACKNOWLEDGEMENT I acknwledge that I have read, understd, and accept the prvisins f this Agreement. Except as expressly supplemented by this Agreement, all ther terms and cnditins cntained in the Agreement remain in full frce and effect. NAME (Please Print) SIGNATURE AGENT NUMBER DATE LPCAH4112 L&P PCA HIPAA

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11 Para infrmacin en españl, visite escribe a la Cnsumer Financial Prtectin Bureau, 1700 G Street N.W., Washingtn, DC A Summary f Yur Rights Under the Fair Credit Reprting Act The federal Fair Credit Reprting Act (FCRA) prmtes the accuracy, fairness, and privacy f infrmatin in the files f cnsumer reprting agencies. There are many types f cnsumer reprting agencies, including credit bureaus and specialty agencies (such as agencies that sell infrmatin abut check writing histries, medical recrds, and rental histry recrds). Here is a summary f yur majr rights under the FCRA. Fr mre infrmatin, including infrmatin abut additinal rights, g t r write t: Cnsumer Financial Prtectin Bureau, 1700 G Street N.W., Washingtn, DC Yu must be tld if infrmatin in yur file has been used against yu. Anyne wh uses a credit reprt r anther type f cnsumer reprt t deny yur applicatin fr credit, insurance, r emplyment - r t take anther adverse actin against yu - must tell yu, and must give yu the name, address, and phne number f the agency that prvided the infrmatin. Yu have the right t knw what is in yur file. Yu may request and btain all the infrmatin abut yu in the files f a cnsumer reprting agency (yur "file disclsure"). Yu will be required t prvide prper identificatin, which may include yur Scial Security number. In many cases, the disclsure will be free. Yu are entitled t a free file disclsure if: a persn has taken adverse actin against yu because f infrmatin in yur credit reprt; yu are the victim f identify theft and place a fraud alert in yur file; yur file cntains inaccurate infrmatin as a result f fraud; yu are n public assistance yu are unemplyed but expect t apply fr emplyment within 60 days. In additin, all cnsumers are entitled t ne free disclsure every 12 mnths upn request frm each natinwide credit bureau and frm natinwide specialty cnsumer reprting agencies. See fr additinal infrmatin. Yu have the right t ask fr a credit scre. Credit scres are numerical summaries f yur credit-wrthiness based n infrmatin frm credit bureaus. Yu may request a credit scre frm cnsumer reprting agencies that create scres r distribute scres used in residential real prperty lans, but yu will have t pay fr it. In sme mrtgage transactins, yu will receive credit scre infrmatin fr free frm the mrtgage lender. Yu have the right t dispute incmplete r inaccurate infrmatin. If yu identify infrmatin in yur file that is incmplete r inaccurate, and reprt it t the cnsumer reprting agency, the agency must investigate unless yur dispute is frivlus. See fr an explanatin f dispute prcedures. Cnsumer reprting agencies must crrect r delete inaccurate, incmplete, r unverifiable infrmatin. Inaccurate, incmplete r unverifiable infrmatin must be remved r crrected, usually within 30 days. Hwever, a cnsumer reprting agency may cntinue t reprt infrmatin it has verified as accurate. Cnsumer reprting agencies may nt reprt utdated negative infrmatin. In mst cases, a cnsumer reprting agency may nt reprt negative infrmatin that is mre than seven years ld, r bankruptcies that are mre than 10 years ld. Access t yur file is limited. A Cnsumer reprting agency may prvide infrmatin abut yu nly t peple with a valid need usually t cnsider an applicatin with a creditr, insurer, emplyer, landlrd, r ther business. The FCRA specifies thse with a valid need fr access. Yu must give yur cnsent fr reprts t be prvided t emplyers. A cnsumer reprting agency may nt give ut infrmatin abut yu t an emplyer, r a ptential emplyer, withut yur written cnsent given t the emplyer. Written cnsent generally is nt required in the trucking industry. Fr mre infrmatin, g t Yu may limit prescreened ffers f credit and insurance yu get based n infrmatin in yur credit reprt. Unslicited prescreened ffers fr credit and insurance must include a tll-free phne number yu can call if yu chse t remve yur name and address frm the lists these ffers are based n. Yu may pt ut with the natinwide credit bureaus at Yu may seek damages frm vilatrs. If a cnsumer reprting agency, r in sme cases a user f cnsumer reprts r a furnisher f infrmatin t a cnsumer reprting agency vilates the FCRA, yu may be able t sue in state r federal curt. FCRA1113 L&P Fair Credit Reprting Act f 2

12 Identity theft victims and active duty military persnnel have additinal rights. Fr mre infrmatin, visit States may enfrce the FCRA, and many states have their wn cnsumer reprting laws. In sme cases, yu may have mre rights under state law. Fr mre infrmatin, cntact yur state r lcal cnsumer prtectin agency r yur state Attrney General. Fr infrmatin abut yur federal rights cntact: TYPE OF BUSINESS: 1.a. Banks, savings assciatins, and credit unins with ttal assets f ver $10 billin and their affiliates. b. Such affiliates that are nt banks, savings assciatins, r credit unins als shuld list in additin t the CFPB: 2. T the extent nt included in item 1 abve: a. Natinal banks, federal savings assciatins, and federal branches and federal agencies f freign banks CONTACT a. Cnsumer Finance Prtectin Bureau 1700 G Street NW Washingtn, DC b. Federal Trade Cmmissin: Cnsumer Respnse Center-FCRA Washingtn, DC (877) a. Office f the Cmptrller f the Currency Assistance Grup 1301 McKinney Street, Suite 3450 Hustn, TX b. State member banks, branches and agencies f freign banks (ther than federal branches, federal agencies, and insured state branches f freign banks), cmmercial lending cmpanies wned r cntrlled by freign banks, and rganizatins perating under sectin 25 r 25A f the Federal Reserve Act c. Nnmember Insured Banks, Insured State Branches f Freign Banks, and insured state savings assciatins b. Federal Reserve Cnsumer Help Center P.O. Bx 1200 Minneaplis, MN c. FDIC Cnsumer Respnse Center 1100 Walnut Street, Bx #11 Kansas City, MO d. Federal Credit Unins d. Natinal Credit Unin Administratin Office f Cnsumer Prtectin (OCP) Divisin f Cnsumer Cmpliance and Outreach (DCCO) 1775 Duke Street Alexandria, VA Air Carriers Asst. General Cunsel fr Aviatin Enfrcement & Prceedings Aviatin Cnsumer Prtectin Divisin Department f Transprtatin 1200 New Jersey Avenue, S.E. Washingtn, DC Creditrs Subject t Surface Transprtatin Bard Office f Prceedings, Surface Transprtatin Bard Department f Transprtatin 395 E. Street, S.W. Washingtn, DC Creditrs Subject t Packers and Stckyards Act Nearest Packers and Stckyards Administratin area supervisr 6. Small Business Investment Cmpanies Assciate Deputy Administratr fr Capital Access United States Small Business Administratin 409 Third Street, S.W., 8 th Flr Washingtn, DC Brkers and Dealers Securities and Exchange Cmmissin 100 F St. N.E. 8. Federal Land Banks, Federal Land Bank Assciatins, Federal Intermediate Credit Banks, and Prductin Credit Assciatins 9. Retailers, Finance Cmpanies, and All Other Creditrs Nt Listed Abve Washingtn, DC Farm Credit Administratin 1501 Farm Credit Drive McLean, VA FTC Reginal Office fr regin in which the creditr perates r Federal Trade Cmmissin: Cnsumer Respnse Center - FCRA Washingtn, DC (877) Business Infrmatin Grup, Inc. A Vertical Screen Cmpany Attn: Cnsumer Disclsure P.O. Bx 541, Suthamptn, PA Tll-free phne FCRA1113 L&P Fair Credit Reprting Act f 2

13 FAIR CREDIT REPORTING ACT DISCLOSURE AND AUTHORIZATION OF CONSUMER REPORT/INVESTIGATIVE CONSUMER REPORT DISCLOSURE Federal law requires yu be advised that in cnnectin with yur applicatin fr appintment with Mnumental Life Insurance Cmpany, Transamerica Financial Life Insurance Cmpany, Transamerica Life Insurance Cmpany, Stnebridge Casualty Insurance Cmpany, Stnebridge Life Insurance Cmpany and/r Western Reserve Life Assurance C. f Ohi, (each individually referred t as the Cmpany ) fr the purpse f selling its prducts, a cnsumer reprt and/r investigative cnsumer reprt may be prepared, whereby infrmatin is btained thrugh credit reprting agencies, previus emplyers, and regulatry, state and lcal law enfrcement databases and thers. Such infrmatin is used alng with ther criteria t help evaluate suitability fr representing the Cmpany s prducts. Yu have a right t request disclsure f the nature and scpe f the investigatin upn written request t ur Administrative Office made within a reasnable time after the receipt f this ntice. A Summary f Yur Rights under the Fair Credit Reprting Act is attached heret. LPIR4112 L&P Investigative Rpt. Disclsure Page 1 f 1

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15 1994 Crime Act Ntice T Applicants The Vilent Crime Cntrl and Law Enfrcement Act f 1994 ( 1994 Crime Act ) makes it a federal crime t: 1. knwingly make false material statements in financial reprts submitted t insurance regulatrs; 2. embezzle r misapprpriate mnies r funds f an insurance cmpany; 3. make material false entries in the recrds f an insurance cmpany in an effrt t deceive fficials f the cmpany r regulatrs regarding the financial cnditin f cmpany; r 4. bstruct an investigatin by an insurance regulatr. The 1994 Crime Act als makes it a federal crime fr individuals wh have been cnvicted f a felny invlving dishnesty, breach f trust, r any f the ffenses listed abve t willfully participate in the business f insurance. The law prvides an exceptin where an individual wh has been cnvicted f any f the felnies described abve has btained written cnsent t wrk in the insurance business frm any insurance regulatry fficial authrized t regulate the cmpany. The penalties fr vilating this law can range up t $50,000 in civil fines and five t fifteen years in prisn. CAN1994 L & P 1994 Crime Act Ntice

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17 CODE OF PROFESSIONAL CONDUCT FOR PRODUCERS AND EMPLOYEES OF the Transamerica Cmpanies 1 (the Cmpany ) Revised June 2012 As a Cmpany, we are cmmitted t treating ur custmers fairly and ethically. That is why we have adpted this Cde fr ur prducers and emplyees. Our prducers (the individuals and firms authrized t sell ur prducts) have a respnsibility t treat ur custmers fairly and ethically. Our emplyees wh supprt ur prducers and serve ur mutual custmers share that respnsibility and trust. The Cmpany applies the fllwing Principles t its markets and lines f business. PRINCIPLES The Cmpany cmmits itself, in all f its markets and business, t: Cnduct business accrding t high standards f hnesty and fairness and t treat ur custmers as we wuld expect t be treated. Prvide cmpetent and custmer-fcused sales and service. Cmpete fairly. Prvide advertising and sales material that is clear, hnest and fair. Handle custmer cmplaints and disputes fairly and prmptly. Maintain a system f supervisin and mnitring reasnably designed t demnstrate the Cmpany s cmmitment t and cmpliance with these principles. 1 Transamerica Cmpanies, as used in this Cde, refers t the life insurance cmpanies and any nn-securities affiliates f the Transamerica grup f cmpanies. This Cde applies t thse cmpanies and t their prducts, including insurance prducts and nninsurance prducts. This Cde des nt apply t ur securities affiliates (e.g., affiliated brker-dealers, investment advisers, transfer agents, mutual fund cmplexes, investment cmpanies and life insurance cmpany separate accunts) because they are each required by their securities regulatrs t have their wn unique cmpliance framewrk, plicies and prcedures. 1

18 In additin, the Cmpany has adpted the fllwing Plicies specific t the Cmpany s prducts (referred t as Prducts ). POLICIES It is the plicy f the Cmpany, in the sale f Prducts, t: Meet the needs f its custmers. The Cmpany will enter int transactins which assist custmers in meeting their needs and bjectives. The Cmpany will have prcedures designed t reasnably assure that recmmendatins made by prducers (r by the Cmpany if n prducer is invlved in the sale) t purchase individual annuity and lng-term care Prducts are suitable based upn relevant infrmatin btained frm custmers. The Cmpany will maintain a prcess t cmply with laws and regulatins that are related t this Cde in the marketing and sale f Prducts. The Cmpany, in cperatin with cnsumers, regulatrs, prducers and thers, will practively seek t imprve the industry s practices fr marketing and sales f Prducts. The Cmpany has adpted and will supprt the cncepts in this Cde f Prfessinal Cnduct. The Cmpany will take crrective actin upn identifying any vilatins f this Cde. Use qualified and trained distributrs and emplyees. The Cmpany will have apprpriate criteria r guidelines fr selecting prducers and apprpriate emplyees f gd character and business repute wh have apprpriate qualificatins. The Cmpany will ensure that prducers are licensed, appinted (where necessary), and meet ther applicable state requirements required t slicit the Cmpany s Prducts. Training will be prvided r made available t prducers and apprpriate emplyees, n hw t cmply with laws and regulatins, with Cmpany prcedures, and with this Cde, in the marketing and sale f Prducts, as apprpriate t the distributin system. Infrmatin will be prvided r made available t prducers and apprpriate emplyees abut the Cmpany s applicable Prduct(s) and the features and peratin f the prduct(s). The infrmatin may be prvided r made available thrugh varius methds, including: sales, marketing, r ther descriptive prduct materials; manuals; training r training materials; sftware; Web sites r system-based infrmatin; r ther apprpriate means. The Cmpany will encurage prducers and apprpriate emplyees t participate in cntinuing educatin designed t prvide current knwledge regarding prducts, industry issues and emerging trends. 2

19 POLICIES (cn t) Cmpete fairly. The Cmpany will engage in fair and active cmpetitin in the marketing and sales f its Prducts. T accmplish this, the Cmpany, and, where apprpriate, its prducers and its emplyees invlved in the sales prcess, will: a) Maintain cmpliance with the applicable state and federal laws fstering fair cmpetitin; and b) Refrain frm disparaging cmpetitrs. Where the sale f an Insurance Prduct invlves a replacement, the Cmpany and, where apprpriate, its prducers will: a) Prvide cnsumers with infrmatin they need t ascertain whether a replacement is apprpriate including reasns why replacement might nt be apprpriate; and b) Have prcedures t review replacement activity which include a system fr tracking, identifying and addressing deviatins frm the Cmpany s replacement plicies and prcedures. Sell fairly and use clear and accurate sales materials. Advertising and sales material that is designed t lead t sales r slicitatin f the Cmpany s Prducts shuld be presented in a manner cnsistent with the needs f the custmer. Such advertising and sales material will be based upn the principles f fair dealing and gd faith and will have a sund basis in fact. Such materials that are presented as part f a sale are clear and understandable in light f the cmplexity f the prduct being sld. Such materials are nt permitted t be used in the sale f the Cmpany s Prducts unless and until they are reviewed and apprved by the Cmpany fr cmpliance with this Cde and with applicable laws and regulatins related t advertising, unfair trade practices, sales illustratins and ther similar prvisins. The Cmpany will maintain prcedures designed t reasnably assure that sales illustratins r ther representatins f premiums and cnsideratins, csts, values and benefits are accurate, fair, and cmplete and cntain apprpriate disclsures. Where apprpriate, guaranteed and nn-guaranteed elements will be clearly identified, distinguished and explained. 3

20 POLICIES (cn t) Apprpriately handle and mnitr cmplaints. The Cmpany will identify, evaluate and handle custmer cmplaints in cmpliance with applicable laws and regulatins. The Cmpany will prvide an easily accessible way fr custmers t cmmunicate cmplaints. The Cmpany will maintain plicies and prcedures designed t reasnably assure that custmer cmplaint infrmatin gathered is analyzed and effrts are made t eliminate their rt causes. The Cmpany has plicies and prcedures t reasnably assure that it makes gd faith effrts t reslve cmplaints and disputes. Supervise and mnitr. The Cmpany s management has established and will enfrce plicies and prcedures reasnably designed t demnstrate the Cmpany s cmmitment t and cmpliance with this Cde. The Cmpany s system f supervisin ver the sales and marketing activities f its prducers and apprpriate emplyees relating t its Prducts is designed t reasnably assure cmpliance with this Cde. In apprpriate distributin systems f independent prducers, the Cmpany may agree that a prducer s firm r ther independent intermediary will perfrm supervisry respnsibilities as specified in a written agreement with the firm r intermediary. The Cmpany will train apprpriate emplyees n this Cde, relevant Cmpany cmpliance plicies and prcedures, and applicable laws and regulatins. The Cmpany will mnitr the sales and marketing practices f its prducers and apprpriate emplyees t ensure cmpliance with this Cde and applicable laws and regulatins. 4