NSS Life Licensing Checklist Please complete the following contracting papers. Remember to sign in the required areas. The more complete the application, the sooner it will be approved. Agents Name: Appointing Agent / Agency: State(s) to be appointed in: (Please include licenses) Commission Level (if unknown, call MESSER 866-568-9649): Writing Agent Checklist MESSER Use Complete application to represent Sign Disclosure and Agent agreement Sign Direct Deposit Form Attach all state licenses for appointment states Attach front page of E&O coverage Please Return by Mail or Fax MESSER Financial Group - Attn: Contracting 4301 Morris Park Dr. Charlotte, NC 28227 Secure Fax: 800-319-5332 Phone 866-568-9649 For Office Use Only Marketing Rep: Date In: Date Out: Notes:
Agent Application for Appointment Name: First Middle Last Address: include city, state and zip code. Please check preferred mailing address. Residence Business Name and Address E-Mail Phone: Please check preferred contact Home Work Fax Cell Date of Birth Social Security Number Do you Carry E&O: Yes, No With: Do you assign commissions? Yes, No If Yes List Assignee: Have you completed an Anti-Money Laundering Course? Yes, No. If yes through LIMRA If elsewhere, list organization and date Background Information Have you ever been convicted of a crime, including felony, misdemeanor or military offense? Yes, No If so,explain in detail the circumstances surrounding the conviction, including the date of conviction. Have you ever been fined by or had your insurance license suspended by the Insurance Commissioner of any state? Yes, No Are you currently appointed with any other Insurance Companies? Yes, No. If yes, please list a few: Agent Signature Date Print Name Managing/General Agent Important Information The facts set forth by me in the application are true and complete. Misrepresentation and/or omissions will cause for termination or failure to contract. The company has authority to contact any and all insurance companies you are currently appointed with to verify information in this application. By filling out this application for appointment, I am genuinely interested in becoming an insurance agent for the National Slovak Society. Signature Date Print Name FORM NO. AAA0001 National Slovak Society of the USA 351 Valley Brook Road McMurray, PA 15317 Phone (724) 731-0094 Fax (724) 731-0146 Page 1 07/07/2008
THE NATIONAL SLOVAK SOCIETY OF THE USA A Fraternal Benefit Society 351 Valley Brook Road, McMurray, PA 15317-3337 AGENT CONTRACT Name SSN or EIN First Middle Last Address Street City State Zip Code DEFINITIONS: The parties agree that any use in the body of this agreement of the terms designated below shall be meant to describe the following: "Society" refers to the National Slovak Society of the USA. "Contract Year" begins on that date that this contract is approved by the Society's Executive Officers. "Managing General Agent" (MGA) is a licensed Agent with reporting responsibility to the Society and who has oversight responsibility for five (5) or more General Agents and/or Agents. General Agent (GA) is a licensed Agent with reporting responsibility directly to either a MGA or the Society and who also has oversight responsibility for at least two (2) Agents. "Agent" is a licensed Agent with reporting responsibility directly to a MGA, a GA or the Society The undersigned parties to this agreement, both of whom are also described above, in consideration of the mutual covenants hereinafter contained, do hereby covenant and agree as follows, to wit: 1. APPOINTMENT, TERM, TERRITORY, DUTIES, RELATIONSHIP Upon execution of this agreement (herein Contract ) by all parties, the Society hereby appoints the above individual as a non-exclusive Agent to the following assemblies and within the following States: By the acceptance of this Contract, the Agent agrees to solicit applications for life insurance and annuity certificates for the Society, and to collect initial first year premiums thereon. While exercising authority under this Contact, the Agent shall observe all laws of the State or States in which the Agent may transact business, all rules and regulations of the Insurance Departments thereof, and all Society rules and regulations including the Society By-Laws. Nothing herein shall be construed to create the relationship of employer and employee between the Society and the Agent. The Agent acknowledges status solely as an independent contractor without authority to represent or bind the Society on any matters beyond that specifically granted by this Contract. However, the Agent shall be a member in good standing of the Society at all times while acting as an Agent. Unless sooner terminated in accordance with the terms hereof, this Contract shall continue for an initial term of one (1) year from the date signed by the Society. Upon expiration of the initial term and in the absence of written notice by either party of an intention to not renew, it shall automatically renew for an additional period of one (1) year subject to the same terms and conditions. Notice of intent to not renew must be given within thirty (30) days following expiration of the preceding term and upon issuance of such notice, termination shall be retroactively applied to the expiration date, subject only to payment of any commissions earned prior to notice of termination. If this line is initialed by the Agent appointed hereunder, it constitutes an acknowledgement by both parties that this appointment has been sponsored by Messer Financial, who is either a MGA or GA for the Society and there does exist a separate business relationship between the Agent and the MGA or GA, which may or may not be reduced to writing. In either event, this Contract is not meant to supersede any such agreement between the Agent and the MGA or GA or to otherwise interfere with that business relationship, except to the extent there is a conflict between any of the provisions of this Contract and that existing between the Agent and the MGA or GA, in which case this Contract shall be controlling. It is further acknowledged that any authority of the Agent to act for or on behalf of the Society is strictly Initial Here 1
limited to that set forth in this Contract (including all restrictions and prohibitions herein specified) and that the MGA or GA has no power or right to expand on that authority. Unless the Agent has signed an Assignment of Commissions form providing for an assignment of any commissions due under this Contract over to the MGA or GA, any commissions earned hereunder will be paid by the Society directly to the Agent. The Society will not be responsible for the payment of any other commissions or compensation that may have been promised to the Agent by the MGA or GA in addition to that which is herein provided. It is further acknowledged the Agent shall be required to report directly to the MGA or GA identified herein, who through their sponsorship has assumed oversight responsibilities for the Agent. However, the Agent shall have a continuing obligation to provide to the Society any records or reports it may from time to time request and to promptly report directly to the Society the violation of any laws, rules, or regulations of either the Society or any governmental entity exercising control over the activities covered by this Contract, whether such violation is committed by the Agent or anyone else acting on behalf of the Society. 2. LICENSE FEES - It is acknowledged the Agent may be required to obtain licenses for the sale of the products being offered by the Society from any State in which the Agent may be soliciting those sales. All Agents under contract with the Society are required to maintain their insurance licenses in the States in which they sell. All fees associated with licensing or continuing education shall be the individual responsibility of the Agent. However, all State appointment fees to sell for the Society shall be paid by the Society. 3. RECORDS AND REPORTS OF THE AGENT - The Agent agrees to keep a full and true record of all business transacted on behalf of the Society, which records shall at all times be open for examination by the Society or its designated representative. The Agent shall also, at such times as the Society may require, forward to the Society a full and detailed statement of accounts in such form as the Society may require, showing all money collected and/or received by the Agent under authority of this Contract. 4. MONEY DUE THE SOCIETY - Money received by the Agent for the Society shall be immediately due and payable in full to the Society without demand. 5. TERMINATION OF CONTRACT A. TERMINATION: I. Either party may terminate this Contract for any reason by giving the other party thirty (30) days advance written notice of intent to do so. II. This Contract may be unilaterally terminated by the Society without advance written notice upon any of the violations of this Contract by the Agent, as are more specifically set forth in Paragraph 11 hereof, or if the Agent should lose their status as a member in good standing of the Society. III. The Agent is required to reach a production level equal to a minimum of five (5) life and five (5) annuity applications per calendar year, together with a minimum of $2,500.00 in annualized life premium or $20,000.00 annuity premium. Failure to meet these minimum production requirements in any given calendar year may result in a termination of this Contract at the sole discretion of the Society. If the initial term of this Contract does not coincide with a calendar year, minimum production levels for that period from commencement of the Contract up to December 31 st of that same year shall be calculated on a prorated basis for the purposes of this Paragraph. IV. In the event of termination of this Contract by either party, all supplies and other property of the Society then in the custody of the Agent, including illustration software, shall be immediately returned to the Society by and at the cost of the Agent. B. TERMINATION FOR DEATH OR FULL DISABILITY: I. This contract will terminate automatically upon the death or full disability of the Agent. II. Upon death, all commissions due and owing the Agent shall be payable to the beneficiary as designated below: In the absence of a designated beneficiary, these commissions shall be payable to the Agent s estate. Initial Here 2
Name Relationship Address III. In the event of termination for death or full disability, renewal commissions shall be considered as fully vested for a maximum of three years following the date of termination. Any renewal commissions that become payable on or before the third anniversary date of termination shall be payable to the former agent in the event of termination for disability, or to the former agent s designated beneficiary or estate in the event of termination for death. Any renewal commissions that become payable after the third anniversary of the termination date shall not be considered as vested and shall be forfeited. If the combined annual renewal commission is less than $1,000.00 for the period considered as vested, the Society shall have the option, at its sole discretion, to make a lump sum settlement of further vested commissions owed reduced to present value. IV. "Full Disability", as used in this section, shall mean the inability of the Agent, as a result of illness or injury, to carry out their normal responsibilities under this Contract for a period of sixty (60) consecutive days. 6. REFUND OF COMMISSIONS The Society shall have the unconditional right to cancel or non-renew any certificate of insurance for any business reason, subject to any applicable laws and regulations concerning the cancellation and non-renewal of insurance policies. If the Society cancels any certificate and returns the premiums paid thereon, the Agent agrees to promptly refund (within thirty (30) days of demand) any compensation previously advanced to the Agent by the Society related to the sale or renewal of that certificate, including any payments made by the Society which had been based on an assumed production level not subsequently attained. If an annuity on which a commission has been paid is surrendered during the first certificate year, there shall be a commission refund due the Society, with the amount of the refund to be determined on a prorated basis related to the balance of time remaining in the first certificate year. Similarly, a commission refund will be due the Society for any partial withdrawals made during the first certificate year, which shall be prorated based on both time remaining and amount withdrawn. With respect to any subsequent deposits made to an annuity account for which a commission has been paid, a prorated commission refund will be due the Society for any withdrawals of $5,000.00 or more that are made within one year of the deposit. For purposes of this paragraph, any partial withdrawals will be applied against those funds most recently deposited. Any refunds due pursuant to this Paragraph may be credited by the Society against other commissions earned by the Agent, but not yet paid. Failure of the Agent to make such refunds in a timely fashion following demand by the Society to do so will be grounds for termination of this Contract. 7. LIMITATION OF AUTHORITY - The Agent shall have no authority to obligate the Society in any manner whatsoever, nor to alter, waive, or change any of the terms, rates, or conditions of the Society's certificates, nor to receive any monies due or to become due to the Society, except as specifically provided herein or as may otherwise be authorized in writing by the Society. The Agent shall not use any advertising or printed matter pertaining to the Society's business except that as may be furnished by the Society, or which may have been pre-approved in writing by the Society. The Agent shall not accept renewal premiums, which shall be payable directly to the Society. 8. INDEBTEDNESS TO THE SOCIETY - To the extent permitted by law, the Society shall at all times have a right of setoff against and/or a first lien upon any compensation due the Agent, including all interest in future compensation, for all claims or debts it may at any and all times have against the Agent. 9. FORBEARANCE NO WAIVER - No forbearance or failure of the Society to require strict compliance on the part of the Agent with respect to any of the provisions of this Contract, whether on one or multiple occasions, shall be construed as a waiver by the Society to insist on strict compliance thereafter. Initial Here 3
10. ASSIGNMENT - No rights, claims, or obligations of the Agent under the terms of this Contract shall be assignable to any third party without the prior written consent of the Society. 11. VIOLATION OF CONTRACT - It is expressly understood and agreed that the Society shall have the right to terminate this contract, and all compensation payable after the date of such termination shall be forfeited upon the occurrence of any of the following events: A. If the Agent should sell or offer to sell, directly or indirectly, to any person or persons, certificates of insurance to be issued by the Society, at any reduction of premiums from the regular rates furnished by the Society or offer any rebate of commission either directly or indirectly, or B. If the Agent should violate any of the provisions of this Contract, or withhold or convert to their own use or for the benefit of others, any money, certificates, or receipts belonging to the Society, or at any time endeavor to induce employees or other registered agents of the Society to leave its service, or to induce its members to relinquish their certificates, or interfere with the collection of renewal premiums, or C. In the event of fraud on the part of the Agent, or D. Upon any violation of the insurance laws or regulations of the State in which the Agent solicits business pursuant to this Contract, or upon violation of any of the By-Laws or other governing rules of the Society. 12. COMMISSIONS - The Agent shall receive compensation, at rates specified in the schedules appearing in Appendix A of this Contract, for certificates issued and approved by the Society and submitted by the Agent. Rates of compensation apply only to certificates currently being issued by the Society on the effective date of this Contract. The Society has the sole right to determine its rates of compensation on any certificates or other products that are not listed in this Contract or Appendix A attached hereto, or on rates and plans not quoted in the Society's current rate book, or on rates or plans that may be adopted hereafter. The Society hereby reserves the unconditional right at any time to modify the commission structure and/or to withdraw from use at any time any form of certificate, benefit rider or provision thereof. In either event, the Society will provide thirty (30) days advance written notice of any revised structure and any commissions not already earned by the effective date of the revisions will be paid in accordance with the revised schedule. All commissions to be paid under this Contract shall be considered earned only upon receipt by the Society of a premium paid thereon. CHARGEBACKS - If any withdrawals of principal are made from any Society annuity after the first contract year, and all or any part of such withdrawal amounts are re-deposited within ninety (90) days from the date of withdrawal, no commission will be considered earned or paid thereon. 13. SCHEDULE OF FIRST YEAR COMMISSIONS AND RENEWALS - The commission schedule for the Agent is attached to this Contract in Appendix A. 14 LIFE INSURANCE RIDERS - Annual and renewal rates of commission for any disability, payor and accidental death benefits shall be the same as are currently payable on the basic certificate to which such benefits may be attached. 15. RENEWAL COMMISSION BUY-OUTS - In the event this Contract is terminated due to lack of production under the provisions of Paragraph 5 (A) (III), future renewal commissions otherwise due the Agent shall be considered as fully vested and payable at the time annual renewal premiums are received by the Society. If at the time of termination the anticipated annual renewal commissions are less than $1,000.00, the Society shall have the right at its sole discretion to offer a buy-out option to the former Agent. 16. EFFECTIVE DATE - The effective date of this Contract shall be the date shown on the signature page hereof when signed by the Society and that date shall be the beginning of the first contract year. This Contract shall supersede any and all contracts and amendments heretofore made between the Agent and the Society, but, Initial Here 4
while this Contract remains in force, any rights of the Agent, under the terms and conditions of any such previous contract and amendment, to receive renewals upon earned premiums under such contract and amendment are continued hereunder and such earned renewals shall be payable at the rate, for the remainder of the period, and on the basis applicable while that contract and amendment remained in force, as provided by each such contract and amendment under which business was written. 17. DISPUTE RESOLUTION - In consideration of the Society entering into this Contract with me, I the undersigned agree to the following: A. Any conflict or dispute over commissions, bonus payments or compensation of any kind claimed by the undersigned shall be submitted to the National Assembly of the Society for their decision. This decision shall be binding on the Society. B. In the event the Agent shall not be satisfied with any decision rendered by the National Assembly, both parties shall then maintain the right to pursue any and all remedies available at law or in equity regarding that dispute. C. Aside from those conflicts referenced in Paragraph 17 (A) above, both parties shall maintain the right to pursue any and all remedies available at law or in equity for a breach of any the provisions of this Contract, subject to the jurisdiction and venue requirements of Paragraph 26 herein. It is further agreed that in the event either party defaults with respect to any obligations to be performed hereunder (excepting those resulting in immediate termination), and said default is not remedied within ten (10) days after sending of a written notice by certified mail to the defaulting party specifying the nature of the default, the defaulting party hereby agrees to indemnify the party injured, or to reimburse him, her or it for any and all reasonable attorneys fees and disbursements resulting from or made necessary by the bringing of any suit or other proceeding, whether by complaint or counterclaim to enforce any obligation or to collect such payment, provided such suit or other proceeding results in a judgment, decree or order in favor of the suing party. In the event such suit or other proceeding results in a judgment, decree or order against the suing party, the suing party shall reimburse the other party for any and all expenses, costs and reasonable attorneys fees resulting from or made necessary by virtue of the bringing of such suit or proceeding. If such default is remedied after the commencement of this suit or other proceeding referred to in this paragraph, the indemnity and reimbursement obligation shall be operative with the same force and effect as if a judgment, decree or order had been made in favor of the party bringing such suit or other proceeding. 18. REPRESENTATION Agent shall utilize his best efforts to service and conserve the Society s business. Without limiting the generality of the foregoing. Agent shall not induce, or attempt to induce, any policyholder to withdraw values in policies in force with the Society for the purpose of entering into any transaction with another Company that will result in compensation directly or indirectly to the Agent. Agent agrees to cooperate fully with the Society to facilitate the investigation and adjustments of any claims when and as requested by the Society. 19. CLAIMS BY THIRD PARTIES - If any claim is made by a third party against any party hereto, whether individually or jointly, by reason of any alleged act or omission of the Agent in connection with activities hereunder, the Society may require the Agent to defend such action; or at its sole option, may defend therein and expend any sums as may be necessary thereof, including legal fees. The Agent shall be chargeable for those amounts as well as with any amount which the Society (in its sole discretion) should pay in any negotiated settlement of the matter. Any such amounts due and payable to the Society shall be immediately paid on demand, except in those cases where, in the sole judgment of the Society, the Agent has not been at fault and should not be held responsible. 20. ILLUSTRATIONS - The Agent is encouraged to use the Illustration software provided by the Society to produce life illustrations for applicants regarding life policies or annuities. However, complete copies of each illustration produced must be sent to the Society for inclusion in the applicant s file. Failure to furnish these illustrations by the Agent will be cause for termination of this Contract. 21. ENTIRE CONTRACT & MODIFICATION - This document constitutes the entire agreement between the parties and any modification or amendment thereto must be in writing and signed by both parties. Execution on behalf of the Society must be made by its President and Secretary-Treasurer or will not be binding. The Initial Here 5
Society has the right to change or amend this Contract at any time with a thirty (30) days advance written notice of its intent to do so. 22. GOVERNING LAW - This Agreement shall be governed by and construed and enforced in accordance with the laws of the Commonwealth of Pennsylvania. 23. HEADINGS FOR REFERENCE ONLY - The section and paragraph headings in this Contract are for convenience of reference only and shall not be deemed to modify or limit the provisions of this Contract. 24. NOTICES - Any notice, communication, demand or other writing (a Notice ) required or permitted to be given, made or accepted by any party to this Contract shall be given by personal delivery to or by depositing the same in the United States mail, properly addressed, postage pre-paid and registered or certified with return receipt requested. A Notice given by personal delivery shall be effective upon delivery and a Notice given by registered or certified mail shall be deemed effective on the second day after such deposit. For purposes of Notice, the addresses of the parties shall be as stated on Page 1 hereof, until changed by a Notice given in accordance herewith. 25. JURISDICTION AND VENUE Both parties do hereby agree that this Contract was executed in Washington County, Pennsylvania, upon acceptance by the Society. Therefore, it is agreed that jurisdiction and venue of any legal proceedings initiated with respect to enforcement or other disputes related to this Contract shall lie exclusively in the Courts of Washington County, Pennsylvania, and by signing this Contract both parties agree to submit to that jurisdiction and not to challenge venue thereof. The National Slovak Society of the United States of America By: National Secretary/Treasurer By: National President Date Seal Agent Date For Messer Financial (MGA) Date Agent Contract Effective July 13, 2009 Initial Here 6
National Slovak Society Assignment of Commissions Name of Assignor Social Security or Tax ID # of Assignor Street Address of Assignor (No PO Box) City, State, Zip Code of Assignor National Slovak Society Agent # Name of Assignee. Street Address of Assignee (No PO Box) Social Security or Tax ID # of Assignee City, State, Zip Code of Assignee National Slovak Society Agent # For good an valuable consideration, the receipt of which Assignor acknowledges, Assignor absolutely assigns all of the Assignor s right, title and interest, in and to the following commissions that are now or may hereafter be due and payable to the Assignor in accordance with the terms and conditions of the Assignor s National Slovak Society General Agent or Agent Contract or commission agreement with the Managing General Agency. The Assignor warrants that this assignment is not for the purpose of circumventing any insurance laws or any other laws and/or regulations. Furthermore, the Assignor also warrants the validity of the assignment, and that there has been assignment for the benefit of creditors, nor outstanding assessments, liens or levies due to unpaid taxes or other obligations of the Assignor. Payment made under this Agreement shall fully release the National Slovak Society, and the Managing General Agent coded above, from all responsibility as to such sum paid. In Witness whereof, the Assignor executes this Absolute Assignment of Commissions at: (City, State) On this date day of, 20 Assignor Signature Name of Corporation (if applicable) Signature of Corporate Officer & Title (if applicable) This Absolute Assignment is effective upon receipt and approval of the original form. Cc: Assignor Assignee Approved and effective:
National Slovak Society Privacy Notice Adopted by the Board of Directors on December 4, 2008, find herewith our Privacy Statement as required through the Gramm-Leach-Billey Act adopted in Washington D.C. to protect the privacy of consumers. As has been the practice at NSS Life, we will not share information with other companies: Privacy Notice Meeting Your Financial Needs While Respecting Your Privacy We understand that you expect privacy and security for your nonpublic personal information that might come into our possession through your fraternal relationship with us. This may include information pertaining to your financial and health affairs, and we are committed to treating your information responsibly. We appreciate your trust and confidence in us, and we will reward that trust by protecting your information. This Privacy Policy describes the standards we follow in handling your information about you and your membership with the Society. We will print a copy of this policy annually in the National News. We will also send you any changes to this policy should and when they occur. Protecting your information: We do not share your personal information with any non-affiliated third party for any purpose. In addition, we have a number of policies, procedures, employee orientation and communication programs in place that are designed to protect the privacy of your information. We expect our officers, employees and licensed agents to comply with these policies. This notice describes how we protect the privacy of your information. Types of information we collect and from what sources: o Applications and other forms that you submit to us, this includes your age, gender, place of birth, health and financial information and beneficiaries. o Information about your transactions with us received from you via mail, telephone, facsimile, or internet. o Health and financial information obtained from local, state and federal agencies. o Health information received from physicians, hospitals and other health-care providers. Third parties to whom we may disclose your information without your prior consent and as permitted by law: o Health information for review to our Medical Examiner or Commercial Underwriter who are under written contract and in agreement with this policy. o Financial or health information to regulatory, law enforcement or other governmental authorities, as may be required by law. o Financial or health information to our Legal Advisor who is in agreement with this policy. o We do not share your non-public information with any other third party. How we protect your nonpublic personal information: o Providing information to you only after we have asked and received from your information that only you should know. o We restrict access to your information by our employees, officers and licensed agents on a need to know basis related to the performance of their duties and in order to provide you with the highest quality of professional service. o We maintain physical, electronic, and procedural safeguards that comply with federal regulations applicable to guarding your information. o Our Executive Officers are responsible for the oversight of our Privacy Policy. Endorsement and agreement: I have read the above National Slovak Society Privacy Statement and agree to the conditions and constraints as they are outlined. As a licensed agent or a staff member of a licensed agent, under contract with the National Slovak Society, I promise to abide by this policy and not share non-public information about current and perspective members of the National Slovak Society. Name Signature APN 0907