CONTRACTING CHECKLIST Incomplete Packets WILL hold up your business. In an effort to make contracting easier, Target Insurance Services, Inc. has gone to an electronic contracting system. We request that you complete the attached Producer Set-Up Packet in its entirety. Once completed, it eliminates you from completing contracting paperwork for each carrier, (except for MassMutual who does not participate in this program). Key things to watch for are: Section 1 Legal questions: If you have answered yes to any of these questions, make sure you: o Provide the date, in MM/DD/YYYY format, of the occurrence, o Provide a full, detailed explanation. Electronic Funds Transfer (EFT) o EFT is MANDATORY for any LIFE business. o You MUST provide a voided check. Section 2 Anti-Money Laundering (AML) o You MUST provide your AML certificate or the date you completed it with LIMRA. If completed with LIMRA, you must provide course title or course number. o *If you have not taken an AML course, click here LIMRA. This will take you to LIMRA so you can register and/or complete the course. Product training certificates (if submitting Long Term Care (LTCi) or Annuity applications) o This includes ALL CE credits that have been taken for LTCi or Annuity training E&O Insurance o A current E&O Certificate needs to be attached with this paperwork. o It MUST list your full name as the insured. Section 3 This packet requires your Signature four times. o After the Legal Questions o On the EFT form o On the Signature Authorization page, inside the Signature box with black ink. o On the HIPAA Business Associate Agreement. Section 4 ALL Carriers require YOU to review, confirm and electronically sign the appointment paperwork once generated. You will get an email from one of the Contracting Specialists below or from contracts@ surancebay.com, with instructions on how to approve and electronically sign the paperwork. (SuranceBay is our third party vendor for our electronic licensing.) Incomplete Packets WILL hold up your business. Please help us make this quick, efficient, and easier for you. Please return COMPLETED packets by Fax: 913.384.3781 OR Email: contracting@targetins.com Rachel Phelps rachelp@targetins.com Direct Line: 913.661.5136 Toll Free: 1.800.999.3026 ext. 2235 Penny Shumaker pennys@targetins.com Direct Line: 913.403-5822 Toll Free: 1.800.999.3026 ext. 2261
Producer Set-Up Packet USE HIGH RESOLUTION SCANNER OR HIGH QUALITY FAX Social Security #: Gender: Date of Birth: / / Last Name: First Name: MI: Phone: Fax: Cell: Title: Mr. Mrs. Miss Marital Status: Married Single Maiden Name: Ms. Dr. Divorced Widower Email: Resident Insurance License #: State Driver's License #: DL State: Residential Address ( PO Boxes) Start Date: / / Line 1: Line 2: City : State: Zip code: Business Address ( PO Boxes) Start Date: / / Line 1: Line 2: City : State: Zip code: Doing Business As: Individual Business Entity Solicitor/LOA If DBA Solicitor/LOA, list who you are assigning commissions to: Complete the following only if DBA a Business Entity: **In order to pay commissions to an agency, the agency must have an insurance license** Company Type: Corporation Partnership LLC LLP EIN: Business Name: Website: Phone: Fax: Your Title: Principal Name: Principal Title: Email: Corporate Address ( PO Boxes) Start Date: / / Line 1: Line 2: City : State: Zip code:
Legal Questions for Contracting and Appointment Requests Please answer the following questions. If you answer YES to any question, be sure to provide a full, detailed explanation including specific dates. Name: 1 Have you ever been charged or convicted of or plead guilty or no contest to any Felony, Misdemeanor, federal/state insurance and/or securities or investments regulations or statutes? Have you ever been on probation? 1A Have you ever been convicted of or plead guilty or no contest to any Felony? 1B Have you ever been convicted of or plead guilty or no contest to any Misdemeanor? 1C Have you ever been convicted of or plead guilty or no contest to a violation of federal or state securities or investment related regulations? 1D Have you ever been convicted of or plead guilty or no contest to a violation of state insurance department regulations or statutes? 1E Has any foreign government, court, regulatory agency, or exchange ever entered an order against you related to investments or fraud? 1F Have you ever been charged with a Felony? 1G Have you ever been charged with a Misdemeanor? 1H Have you ever been on probation? 2 Have you ever been or are you currently being investigated, have any pending indictment, lawsuits, or have you ever been in a lawsuit with an insurance company? 2A Are you currently under investigation by any legal or regulatory authority? 2B Have you been under investigation by any insurance company? 2C 2D Have you ever been or are you currently involved in any pending indictments, lawsuits, civil judgments or other legal proceedings (civil or criminal)(you may omit family court). Have you ever been named as a defendant or codefendant in a lawsuit, or have you ever sued or been sued by an insurance company? 3 Have you ever been alleged to have engaged in any fraud? 4 Have you ever been found to have engaged in any fraud? 5 5A Has any insurance or financial services company or broker-dealer terminated your contract or appointment or permitted you to resign for reason other than lack of sales? Were you fired because you were accused of violating insurance or investment related statures, regulations, rules or industry standards of conduct? 5B Were you fired because you were accused of fraud or the wrongful taking of property? 5C 6 7 Failure to supervise in connection with insurance or investment related statues, regulations, rules or industry standards of conduct? Have you ever had an appointment with any insurance company denied or terminated for cause? Does any insurer, insured, or other person claim any commission chargeback or other indebtedness from you as a result of any insurance transactions or business?
8 Has any lawsuit or claim ever been made against you, your surety company, or errors and omissions insurer arising out of your sales or practices, or, have you been refused surety bonding or E&O coverage? 8A Has a bonding or surety company ever denied, paid on or revoked a bond for you? 8B Has any Errors & Omissions (E&O) carrier ever denied, paid claims on or cancelled your coverage? 9 Have you ever had an insurance or securities license denied, suspended, cancelled or revoked? Has any state or federal regulatory body found you to have been a cause of an investment or insurance related business having its authorization to do business denied, suspended, revoked, or restricted? Has any state or federal regulatory agency revoked or suspended your license as an attorney, accountant, or federal contractor? Has any state or federal regulatory agency found you to have made a false statement or omission or been dishonest, unfair, or unethical? 10 11 12 13 Have you had any interruptions in licensing? 14 Has any state, federal or self-regulatory agency filed a complaint against you, fined, sanctioned, censured, penalized or otherwise disciplined you for a violation of their regulations or state or federal statutes? Have you ever been the subject of a consumer initiated complaint? 14A Has any regulatory body ever sanctioned, censured, penalized or otherwise disciplined you? 14B Has any state, federal, or self-regulatory agency filed a complaint against you, fined o sanctioned you? 14C Have you ever been the subject of a consumer initiated complaint? 15 Have you personally or any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or declared bankruptcy? 15A Have you personally filed a bankruptcy petition or declared bankruptcy? 15B Has any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or been declared bankrupt either during your association or within five years after termination of such association? 15C Is the bankruptcy pending? 16 Are there any unsatisfied judgments, garnishments or liens against you? Are you connected in any way with a bank, savings & loan association, or other lending or 17 financial institution? 18 Have you ever used any other names or aliases? Do you have any unresolved matters pending with the Internal Revenue Service or other 19 taxing authority? If you answered any questions YES, provide an explanation that includes dates, actions, and descriptions. Attach additional paper if necessary. I attest that the information I have provided is true to the best of my knowledge. I acknowledge that if any information changes, I will notify my agency office within 5 days of such change. Further, I understand that my agency may contact me when I need to answer carrier specific questions. Signature: Date:
LETTER OF EXPLANATION *NOTE* Use additional paper if necessary Date of Action: / / Action: Reason: Explanation: Date of Action: / / Action: Reason: Explanation: Date of Action: / / Action: Reason: Explanation: LICENSES **Anti-Money Laundering Training Required** AML training must be completed within two years to be valid** AML Provider: LIMRA NONE OTHER Date Completed: / / If Other, Provide Certificate of Completion. **Nationwide requires MetLife training only annually; accepts MetLife training ONLY through accepts LIMRA training through LIMRA Are you a Registered Rep with FINRA? If, Broker/Dealer Name: CRD #:
History Employment -- Please provide past 5 years of employment history: From: / / To: / / Company: Position: Address: From: / / To: / / Company: Position: Address: From: / / To: / / Company: Position: Address: Address History -- Please provide past 5 years of address history: From: / / To: / / Line 1: Line 2: City : State: Zip code: From: / / _ To: / / Line 1: Line 2: City : State: Zip code: From: / / To: / / Line 1: Line 2: City : State: Zip code:
Replace this page with a copy of your E&O Insurance Certificate of Coverage IMORTANT: E & O Certificate must list your full name as the insured. Please refer to the following examples. CORRECT: My Insurance Agency Inc. Joe Agent 123 Main Ave City, State, 12345 INCORRECT: My Insurance Agency Inc. 123 Main Ave City, State, 12345 If individual name is not listed correctly please provide a letter from the E&O Carrier listing agents covered under agency policy.
ELECTRONIC FUND TRANSFERS (EFT)
Signature Authorization PLEASE READ THIS AUTHORIZATION, SIGN IN THE BOX BELOW AND SUBMIT THIS FORM BY FOLLOWING THE INSTRUCTIONS PROVIDED ON THE COVER PAGE. I,, hereby authorize SuranceBay, LLC and its general agency customers (the Authorized Parties ) to affix or append a copy of my signature, as set forth below, to any and all required signature fields on forms and agreements of any insurance carrier (a Carrier ) designated by me through the SureLC software or through any other means, including without limitation, by e-mail or orally. The Authorized Parties shall be permitted to complete and submit all such forms and agreements on my behalf for the purpose of becoming authorized to sell Carrier insurance products. I hereby release, indemnify and hold harmless the Authorized Parties against any and all claims, demands, losses, damages, and causes of action, including expenses, costs and reasonable attorneys' fees which they may sustain or incur as a result of carrying out the authority granted hereunder. By my signature below, I certify that the information I have submitted to the Authorized Parties is correct to the best of my knowledge and acknowledge that I have read and reviewed the forms and agreements which the Authorized Parties have been authorized to affix my signature. I agree to indemnify and hold any third party harmless from and against any and all claims, demands, losses, damages, and causes of action, including expenses, costs and reasonable attorneys' fees which such third party may incur as a result of its reliance on any form or agreement bearing my signature pursuant to this authorization. Please sign in the center of the box below. Please use BLACK ink. PRODUCERIDXXX
Dear Valued Business Associate: RE: HITECH Act and Related Changes to Procedure We want to start by thanking you for favoring Target Insurance Services, Inc with much of your clients life, long term care insurance, disability income and fixed annuity business. It s always our pleasure to be of service and look forward to many more years of shared risk management successes. Today, I would like to discuss with you the HITECH Act passed in 2009. The HITECH Act is a new law designed to implement and promote electronic health record keeping and electronic record transactions. In order to ensure that the electronic record keeping and transactions meet certain security requirements, the Act instituted several rules for security and encryption in the HITECH Enforcement Rule. The HITECH Enforcement Rule went into effect on September 23, 2013. Some of the major changes that came about as a result of the HITECH Act were the following: Business associates and their subcontractors are now subject to the same fines and penalties as covered entities for violation of HIPAA; Updated definition of business associate to emphasize that a business associate includes anyone who creates, receives, maintains, or transmits protected health information PHI on behalf of a covered entity including, but not limited to legal, IT, financial, consulting, billing and claims services; The Act emphasizes that individuals are subject to fines and not just organizations; Finally, the Act requires business associates must enter into business associate agreements with subcontractors that outline each party s PHI obligations. This final new regulation is why we are writing to you. The Act now requires you, as a subcontractor of a business associate, to keep all protected health information secure. This
will most impact you as it relates to storage of information on your computers, along with sending and receiving e-mail containing PHI. We can no longer send unsecure e-mail nor should you on certain emails which contain PHI. As required by this Act, we enclose a HIPAA Business Associate Agreement that you will need to execute. We want to let you know that we have personally signed these documents with our insurance carriers. As we have stated above, the new requirements require that we enter into a Business Associate Agreement with you as one of the subcontractors. What this means going forward is that we must remember that each of us is subject to HIPAA and the penalty provisions if we violate HIPAA primary laws. It is not likely that we would need to change our behavior beyond securing PHI, but this new law puts the burden on each of us to prove our compliance. If you have any questions regarding your interactions with us, please do not hesitate to contact Nita Mead, our Information Security Officer. We would suggest that if you have specific questions regarding the Act, you direct those questions to your legal counsel. Again, we want to thank you for your willingness to work with us. It is always a pleasure doing business with you, and hope to continue to do so.
HIPAA BUSINESS ASSOCIATE AGREEMENT THIS HIPAA BUSINESS ASSOCIATE AGREEMENT (hereinafter Agreement ), made the day of,, is between Target Insurance Services, Inc. (as defined herein) and (hereinafter Subcontractor ). Target Insurance Services, Inc. and Subcontractor may be referred to herein individually as Party or collectively as Parties. BACKGROUND Target Insurance Services, Inc., which is made up of business associates of one or more covered entities, acknowledges that it is subject to the Privacy and Security Rules (45 CFR Parts 160 and 164) promulgated by the United States Department of Health and Human Services Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191. In the course of carrying out its business with Target Insurance Services, Inc., Subcontractor may come into contact with, use, or disclose Protected Health Information ( PHI ). In accordance with the federal privacy and security regulations set forth at 45 CFR Part 160 and Part 164, Subparts A, C, D, and E, which require Target Insurance Services, Inc. to have a written contract or other arrangement with each of its subcontractors, the Parties wish to establish satisfactory assurances that Subcontractor will appropriately safeguard PHI that Subcontractor may receive (if any) from or on behalf of Target Insurance Services, Inc., and, therefore, agree to this Agreement. Catch-all definition: DEFINITIONS The following terms used in this Agreement shall have the same meaning as those terms in the HIPAA Rules: Breach, Data Aggregation, Designated Record Set, Disclosure, Health Care Operations, Individual, Minimum Necessary, tice of Privacy Practices, Protected Health Information, Required by Law, Secretary, Security Incident, Subcontractor, Unsecured Protected Health Information, and Use. Specific definitions: (a) Business Associate. The term "business associate" shall generally have the same meaning as the term "business associate" at 45 CFR 160.103, and in reference to the party to this Agreement, shall mean Target Insurance Services, Inc. (b) Covered Entity. The term "Covered Entity" shall generally have the same meaning as the term "covered entity" at 45 CFR 160.103. (c) Subcontractor. The term Subcontractor shall generally have the same meaning as the term subcontractor at 45 CFR 160.103, and in reference to the party to
this Agreement, shall mean. (d) HIPAA Rules. The term "HIPAA Rules" shall mean the Privacy, Security, Breach tification, and Enforcement Rules at 45 CFR Part 160 and Part 164. OBLIGATIONS AND ACTIVITIES OF SUBCONTRACTOR Subcontractor agrees to the following material duties and obligations to: (a) (b) (c) (d) (e) (f) (g) (h) t use or disclose Protected Health Information other than as permitted or required by the Agreement, a written Agreement between the Parties, or as required by law; Use appropriate safeguards, and comply with Subpart C of 45 CFR Part 164 with respect to electronic Protected Health Information, to prevent use or disclosure of protected health Information other than as provided for by the Agreement; Report to Target Insurance Services, Inc. any use or disclosure of Protected Health Information not provided for by the Agreement of which it becomes aware, including breaches of unsecured Protected Health Information as required at 45 CFR 164.410, and any security incident of which it becomes aware within 20 days of becoming aware of such use or disclosure or incident; In accordance with 45 CFR 164.502(e)(1)(ii) and 164.308(b)(2), if applicable, ensure that any subcontractors of Subcontractor that create, receive, maintain, or transmit Protected Health Information on behalf of Subcontractor or Target Insurance Services, Inc. agree to the same restrictions, conditions, and requirements that apply to Subcontractor with respect to such information; Make available Protected Health Information in a designated record set to the covered entity, Target Insurance Services, Inc., or the "individual or the individual's designee" as necessary to satisfy a covered entity s or Target Insurance Services, Inc. obligations under 45 CFR 164.524; Make any amendment(s) to Protected Health Information in a designated record set as directed or agreed to by Target Insurance Services, Inc. covered entity or Target Insurance Services, Inc. pursuant to 45 CFR 164.526, or take other measures as necessary to satisfy a covered entity s or Target Insurance Services, Inc obligations under 45 CFR 164.526; Maintain and make available the information required to provide an accounting of disclosures to Target Insurance Services, Inc. covered entity, Target Insurance Services, Inc, or an individual as necessary to satisfy a covered entity s or Target Insurance Services, Inc obligations under 45 CFR 164.528; To the extent Subcontractor is to carry out one or more of Target Insurance
Services, Inc. obligation(s) under Subpart E of 45 CFR Part 164, comply with the requirements of Subpart E that apply to Target Insurance Services, Inc in the performance of such obligation(s); and (i) (j) Make its internal practices, books, and records available for purposes of determining compliance with the HIPAA Rules. At the request of Target Insurance Services, Inc, provide proof of policies and procedures evidencing compliance with this Agreement and 45 CFR Part 160 and Part 164. SUBCONTRATOR S DUTY TO NOTIFY INDIVIDUALS At the request of Target Insurance Services, Inc., Subcontractor agrees to provide breach notification to individuals, the HHS Office for Civil rights (OCR), and the media, on behalf of Target Insurance Services, Inc. or Subcontractor of breaches for which Subcontractor is responsible. PERMITTED USES AND DISCLOSURES BY SUBCONTRACTOR (a) (b) (c) (d) Subcontractor may only use or disclose Protected Health Information as necessary to perform its work under its contract or agreement with one or more of Subcontractor s Covered Entities. Subcontractor may use or disclose Protected Health Information as required by law. Subcontractor agrees use, disclose, and request only the minimum necessary amount of Protected Health Information needed to accomplish the purpose of the use, disclosure, or request. Subcontractor may not use or disclose Protected Health Information in a manner that would violate Subpart E of 45 CFR Part 164 if done by Target Insurance Services, Inc. or a covered entity. OBLIGATIONS OF TARGET INSURANCE SERVICES, INC. (b) (c) Target Insurance Services, Inc. shall notify Subcontractor of any changes in, or revocation of, the permission by an individual to use or disclose his or her Protected Health Information, to the extent that such changes may affect Subcontractor s use or disclosure of Protected Health Information. Target shall notify Subcontractor of any restriction on the use or disclosure of Protected Health Information that Target Insurance Services, Inc. has agreed to or is required to abide by under 45 CFR 164.522, to the extent that such restriction may affect Subcontractor s use or disclosure of Protected Health Information.
PERMISSIBLE REQUESTS BY TARGET INSURANCE SERVICES, INC. Target Insurance Services, Inc. shall not request Subcontractor to use or disclose Protected Health Information in any manner that would not be permissible under Subpart E of 45 CFR Part 164 if done by Target Insurance Services, Inc. or a covered entity. TERM AND TERMINATION (a) (b) (c) (d) Term. The Term of this Agreement shall be effective as of, and shall only terminate if Target Insurance Services, Inc. terminates for cause as authorized in paragraph (b) of this Section. Termination for Cause. Subcontractor authorizes termination of this Agreement by Target Insurance Services, Inc., if Target Insurance Services, Inc. determines Subcontractor has violated a material term of the Agreement. Obligations of Subcontractor upon Termination. Upon termination of this Agreement for any reason, Subcontractor shall return to Target Insurance Services, Inc. or, if agreed to by Target Insurance Services, Inc., destroy or transmit to another subcontractor of Target Insurance Services, Inc. all Protected Health Information received from Target Insurance Services, Inc., or created, maintained, or received by Subcontractor on behalf of Target Insurance Services, Inc, that the Subcontractor still maintains in any form. Subcontractor shall retain no copies of the Protected Health Information. Survival. The obligations of Subcontractor under this Agreement shall survive the termination of this Agreement. MISCELLANEOUS (a) (b) (c) Regulatory References. A reference in this Agreement to a section in the HIPAA Rules means the section as in effect or as amended. Amendment. The Parties agree to take such action as is necessary to amend this Agreement from time to time as is necessary for compliance with the requirements of the HIPAA Rules and any other applicable law. Interpretation. Any ambiguity in this Agreement shall be interpreted to permit compliance with the HIPAA Rules. INDEMNIFICATION Subcontractor agrees to indemnify and hold harmless Target Insurance Services, Inc. from and against all claims, demands, suits, costs, expenses, liabilities, fines, penalties, losses, and damages including, without limitation, direct, indirect and consequential damages, court costs
and reasonable attorney's fees, arising from or in any respect related to a breach of this Agreement, an unauthorized use or disclosure of PHI, or a violation of 45 CFR Part 160 or Part 164 committed by Subcontractor, its employees, or its agents. Subcontractor signature Printed Name & Title