American General Life Insurance Company A member of American International Group, Inc. (). Producer Appointment Application Part 1 Applicant Data - Please print clearly. To be completed by all producers, partners and principals of corporations. Appointment for: Q Individual Q Corporation [^Partnership [ULLC (Please check individual or individual and entity types. If checking both individual and entity, the individual on this form must be a principal of the corporation.) Will any New Business be submitted within the next 30 days? Q] Yes \Z\ No Policy Number: Proposed Insured Name: Personal Information Social Security Number: - - Full Name: Last Name First Name Middle Initial Business Address*: *AII commission statements will be mailed to the business address unless you have assigned commissions. Residence Address (no PO boxes): Bus. Phone: ( ) Fax Number: ( ) Home Phone: ( ) E-mail Address: of Birth: Direct Manager (if applicable): Sex: Q Male Q Female Corporation / Partnership Information (if applicable): If applicant is a corporation, LLC or a partnership, each principal signing on behalf of the corporation or partnership must complete a separate Appointment Application form. Only one of the principals can use this form for his/her individual appointment information. Company Name: Company Tax ID: Principal: State of Incorporation: License Information Resident State: Residence License Number: Do you wish to be appointed in any nonresident states? C] Yes Q No If Yes, please list requested states(s) If currently NASD registered, who is your Broker Dealer? CRD Number: 225-AANC REV0314 Page 2 of 5
American General Life Insurance Company A member of American International Group, Inc. (). Producer Appointment Application Anti-Money Laundering Federally Mandated Training: Have you taken the LIMRA AML Training Course within the last 12 months? Q Yes Q No* * If no, the LIMRA course must be completed within 14 days of the completion of this application or appointment will be denied. American General Life Insurance Company only recognizes LIMRA AML Courses. Part 2 Confidential History - must be completed by all applicants. Confidential history/background information (Write Y for "yes" and N for "no" in blanks - if Yes, explain below) (All answers will be verified by a background investigation / credit report.) Y/N 1. Have you ever been convicted of or plead guilty or no contest to a felony? 2. Have you ever been convicted of or plead guilty or no contest to a misdemeanor? 3. Are you currently under investigation by any legal or regulatory authority? 4. Do you now owe money to any insurance company? 5. Have you had a salary garnished or had liens or judgments against you? 6. Has any insurance department, government agency or self-regulatory authority ever denied, suspended, revoked, censured or barred your license or registration or disciplined you with fines or by restricting your activity? 7. Have you ever been the subject of a consumer-initiated complaint? 8. Have you ever been the subject of a proceeding by any self-regulatory body or any securities, commodities or insurance regulatory body or organization? 9. Has a bonding company ever denied, paid out on or revoked a bond for you? 10. Have you ever had a claim filed against your professional liability or errors and omission insurance coverage? 11. Has any insurance company or securities broker-dealer terminated your contract or permitted you to resign for a reason other than lack of sales? 12. Have any of the American General Affiliates, as identified on page 4 of the application, ever declined to appoint you, refused to contract you or terminated your contract? Details of "Yes" answers. Provide date of occurrence, explanation, resolution and applicable court documents. (Insufficient information will result in processing delays. If necessary, use additional pages.) - _ 225-AANC REV0314 Page 3 of 5
American General Life Insurance Company A member of American International Group, Inc. (). Producer Appointment Application Part 3 Applicant Authorization Social Security Number - - I have read and received, as of the date indicated below, the notice concerning investigative consumer reports, as required by law. I understand that by signing this form, I authorize the American General Affiliates* that I have requested appointments with to investigate my background, including my credit history and interviews with former employers. I agree that if any of my answers to the questions in Part 2 change, I will notify, in writing, the Licensing department at my primary appointment company as designated in Part 1 within 10 business days of the incident which would cause an answer to change. I understand that falsification of information or failure to update the answer on this application may result in termination of appointment(s) with all American General Affiliates. In addition, I authorize the American General Affiliates that have appointed me to report information about earnings and debit balances to any credit bureau or similar organization. If I am seeking an appointment to sell variable insurance products, I authorize American General Securities Incorporated to verify my previous employment and securities registration history through the CRD system. I authorize American General Affiliates to share background, licensing, applicant data and other information that they have about me. By signing the authorization, I certify that my E&O policy extends coverage to the person or entity requesting contracting and/or appointment. I agree to provide a copy of the E&O policy, if requested. Further, I understand that I am responsible for maintaining at least $1 million per act (KY requires $2 million) of Errors & Omissions coverage without interruption while my contract and appointment(s) are active with American General Affiliates. I further understand and acknowledge that this is a minimum level only, and if my E&O coverage needs are in excess of $1 million, I agree to ensure that my E&O coverage needs are addressed appropriately. Under penalties of perjury, I certify: that the number shown on this application is my correct Social Security or Tax Identification number; and I am not subject to backup withholding under Section 3406 (a)(1)(c) of the Internal Revenue Code. The Internal Revenue Service does not require my consent to any provision of this document other than the certification required to avoid backup withholding. Producer Signature: : * American General Affiliates include the following life insurance companies: American General Life Insurance Company, The United States Life Insurance Company in the City of New York. Members of American International Group, Inc. (). 225-AANC REV0314 Page 4 of 5
AMERICAN GENERAL LIFE INSURANCE COMPANY STANDARD AGENT AGREEMENT (this "Agreement") by and between American General Life Insurance Company (the "Primary Company") and each Affiliated Insurer made a party to this Agreement, and ("Standard Agent") If Standard Agent is a Corporation, the full corporate name must appear above, and an authorized officer must sign and indicate the officer's title. If Standard Agent is some other legal entity, the full name of such entity must appear above, and a person authorized to sign must sign and indicate such person's title. Individual Social Security Number: - - Corporation or Other Legal Entity Tax Identification Number: Standard Agent: Signature The products of Primary Company and each Affiliated Insurer are separately underwritten and independently supported by each respective insurer. To be completed by Primary Company: Contract : Standard Agent Number: Authorized Company Signature: AGLA225B-SAA REV1013 Page 1 of 16
AMERICAN GENERAL LIFE INSURANCE COMPANY APPOINTED AGENT AGREEMENT (this "Agreement") by and between American General Life Insurance Company (the "Primary Company") and each Affiliated Insurer made a party to this Agreement, and ("Appointed Agent") If Appointed Agent is a Corporation, the full corporate name must appear above, and an authorized officer must sign and indicate the officer's title. If Appointed Agent is some other legal entity, the full name of such entity must appear above, and a person authorized to sign must sign and indicate such person's title. Individual Social Security Number: - - Corporation or Other Legal Entity Tax Identification Number: Appointed Agent: Signature Third-Party Acknowledging Above-Signed Appointed Agent as Subagent: Signature (principal) Legal Name of Corporation, Partnership, or Legal Entity Tax ID Number The products of Primary Company and each Affiliated Company are separately underwritten and independently supported by each respective Company. To be completed by Primary Company: Contract : Appointed Agent Number: Authorized Company Signature: AGLA225B-AA REV1013 Page 1 of 14
W-9 Form (Rev. December 2011) Department of the Treasury Internal Revenue Service Name (as shown on your income tax return) Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. CvJ a) Cl c o & c 4* L. o o 3 V) Q. o a> a. </) <i) CO Business name/disregarded entity name, if different from above Check appropriate box for federal tax classification: Individual/sole proprietor EH C Corporation Q S Corporation Q Partnership Q Trust/estate I I Exempt payee Q Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) I I Other (see instructions) Address (number, street, and apt. or suite no.] Requester's name and address (optional) City, state, and ZIP code List account number(s) here (optional) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to qet a TIN on page 3. Note, if the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Part II Certification Under penalties of perjury, I certify that: Social security number Employer identification number 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4. Sign Here Signature of U.S. person General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income. Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: An individual who is a U.S. citizen or U.S. resident alien, A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, An estate (other than a foreign estate), or A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners' share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. Cat. No. 10231X Form W-9 (Rev. 12-2011) -
Instructions American General Life Electronic Funds Transfer Request and Authorization For Partners Group Commission Payments Complete the following steps to authorize direct deposit of Commission Payments. 1. This form may be filled out using Adobe Reader, then printed and signed. It may also be printed and completed manually. "Please type or print legibly" 2. Fill out the "EFT Direct Deposit Information" below. Sign and date the form. 3. Include a copy of blank check (for checking deposit) or deposit slip (for savings deposit). NOTE: It is required that the name on the bank account matches the name on the contract. 4. FAX or Email this form and the copy of your blank check, deposit slip or letter from your banking institution to: FAX: 615-749-2051 OR Email: nevvcareersupport@agla.com The rooting and account numbers may appear in different places on your check. Do nol use a deposit slip to verify the routing number. The ning (9>-digit routing number should start in the range of 01-12: 21-32 or 61-72. It must not start with a 5. If you want your paycheck deposited into a savings account, contact your financial institution for the routing and account number. EFT Direct Deposit Information Agent Name: Contact Number: Contact Name: PG Service Number:, Bank Name: Branch Location: Branch City, State, Zip: Bank Phone No. Remit Address: Checking or Savings City, State, Zip:_ Cancel EFT Transit Routing No:_ I Change Account or Transit Routing No. (Please Include a copy of your new blank check or Bank Account No:_ Authorization deposit slip for account verification) authorize American General Life and the Bank listed above to issue electronic funds transfers for payment of commissions directly to my account. If funds to which I am not entitled are deposited to my account, I authorize to direct the bank to return said funds. This authority shall remain in effect until 1 cancel. Agent Signature American General Life ALL rights reserved. PG619EFT (0804) Revised 03/04/2014