** A T T E N T I O N ** THIS PAPERWORK MUST BE RETURNED TO YOUR GENERAL AGENCY. Failure to return to your General Agent will result in a delay of the appointment and possible rejection, by the carrier, of any business submitted.
IMPORTANT NOTICE: CE credits may be required to write Long Term Care insurance Please be advised that most states require special CE credits to write Long Term Care insurance (LTCi). Credit requirements usually consist of an 8 hour NAIC or Partnership course and/ or additional state specific CEs. CEs are required for resident and signing states for most carriers. Some states have reciprocity. Policies cannot be issued by any carrier if the writing agentt has not complied with all CE requirements. Thank you for your attention to this matter! FOR PRODUCER USE ONLY - not intended for use in solicitation of sales to the public. Products offered through Crump are not approved for use in all states and may not be available to all producers. 09.10 LTCI10-1356-A
Appointment Data Sheet Licensee Last Name First Name Middle Initial Social Security Number Date of Birth License State(s) Needing JH Appointment Business Address (policies & correspondence mailed here) City State Zip Resident Address City State Zip Phone Number (required) Fax Number Required E-Mail Address Not Paid Direct Paid Direct Commission Level: (Contact and Commission schedule must accompany this data sheet) General Agency Name Principal Agent s Name Agency Tax ID Managing General Agency Name Managing General Agent s Name A. Agents who will be paid commission from the General Agent need only complete this sheet. B. Agents who will be paid directly by John Hancock: 1. Complete this LTC Appointment Date Sheet. Commission level must be indicated on this sheet. 2. Read, date, and sign the Contract. 3. If commission is to be paid to someone other than yourself or to a corporation, complete Assignment of Commission form and attach it to the LTC Appointment Date Sheet. Please attach the following: Please send all materials to: 1. A current insurance license copy for each state in which you wish to sell. 2. This completed appointment form. 3. Copies of completion of any additional requirements to sell LTCI as may be required in the states including continuing Education, Producer Training or Partnership Training certifications. 4. Copy of Errors and Omissions certificate of insurance or declarations page including Limits of Liability, Policy Number, Insurer, Policy Expiration Date, Products/Services Covered. 5. Attached Producer Background Information Questionnaire. 6. Attached commission schedule if paid by John Hancock. 7. Attached assignment of commission form and licenses if assigning commissions. 8. All commission forms and licenses if assigning commissions. 9. All commission levels must be approved by the General Agent & Managing General Agent. (Overnight Address) John Hancock LTC Licensing, B-5 200 Berkeley Street Boston, MA 02117 (Postal Address) John Hancock Attn: LTC Licensing, B-5 One John Hancock Way, Suite 1600 Boston, MA 02117 HOME OFFICE USE ONLY:PAYROLL NUMBER/EFFECTIVE DATE Long-term care insurance is underwritten by John Hancock Life Insurance Company (U.S.A), Boston, MA 02117 (not licensed in New York) and in New York by John Hancock Life & Health Insurance Company, Boston, MA 02117. LTC-1005 3/2011 3
Producer Background Information Questionnaire The following questions are to assist John Hancock* ( the Company ) in selecting reputable, trustworthy representatives to sell and promote its Long-Term Care Insurance products. The Company will use the information in making an informed decision regarding the appropriateness of an appointment. Please answer all questions. If you answer yes to any of these questions, please attach a separate sheet with details. A yes answer will not automatically cause your request for appointment to be denied, but the Company will need you to provide a sufficient explanation. 1. Are you currently charged with, or have you ever pled guilty or no contest to, or been convicted of, any crime (excluding minor traffic offences)? 2. Are you currently or have you ever been the subject of any lawsuit, claim, investigation, or proceeding alleging breach of trust or fiduciary duty, fraud, or any other act of dishonesty? 3. Have you ever had your insurance license or registration suspended or revoked, are you now or have you ever been the subject of a professional license/registration or market conduct investigation, claim, or proceeding? 4. Have you ever been involuntarily terminated or permitted to resign from employment, or from an agent or representative appointment, with any insurance or other financial services company, other than for lack of production? 5. Has a bonding, surety or E&O provider ever denied an application or claim, made payment for you, or terminated your coverage? 6. Are you delinquent in any personal or business financial obligations, or does any insurance or financial services company hold a claim against you for commission debit balances? 7. Are there any outstanding judgments, liens, or claims against you, including delinquent tax obligations, or have you or any business in which you were or are an owner, partner, officer, or director, ever filed for bankruptcy? Bankruptcy discharge date: 8. Have you ever conducted business under another name? 9. At any time in the past 10 years, have you or any business in which you were an owner, partner, officer, or director, been involved in any regulatory, civil, or criminal matters not disclosed above? Declaration and Acknowledgment: I hereby certify that the responses I have provided to the questions above are accurate and complete, and acknowledge that my request for appointment may be terminated based on any false, omitted or fraudulent information. Producer Name (please print): Producer Signature: Date: John Hancock refers to the John Hancock Life Insurance Company (U.S.A.), Boston, MA 02117 (not licensed in New York), and to John Hancock Life & Health Insurance Company, Boston, MA 02117 4 Yes No
Certification and Acknowledgement Form for Compliance With the Training Requirements in Michigan for Producers Selling, Soliciting, or Negotiating Long Term Care Insurance I herby acknowledge and certify that I have: Read and understand the content of the NAIC A Shopper s guide to Long Term Care Insurance (LTC-1059 2006 3/06), the Michigan information regarding Adult Financial Exploitation, and completed these requirements on the date shown below. Signature Full Name (Print) Soc. Sec. Number Agency/ORD Code Date Signed Company Name ORD. code (if applicable) Date Requirements Met After completing this certification, please: Fax to: Or Mail to: John Hancock Licensing 617-450-8057 LTC Licensing, B-5-01 John Hancock Life Insurance Company 200 Berkley Street Boston, MA 02116 LTC-MI Training Cert 11/2007
Crump Use Only: Recorded by Date Assignor Paragon Agent # Assignee Paragon Agent # Assignment of Commissions (Agent) 03-25-10.doc ABSOLUTE ASSIGNMENT OF COMMISSIONS NOTE: Complete this form in full. If a corporate-agency is the assignor, a certified copy of corporate resolution authorizing the Assignment of Commissions must accompany this form. FOR VALUE RECEIVED, the undersigned, (Name of Assignor) (SS# or Tax ID# of Assignor) ( Assignor ), hereby absolutely sells, assigns, transfers and sets over unto, (Name of Assignee) (SS# or Tax ID# of Assignee) ( Assignee ), 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 contract or commission agreements with the insurance company and/or Crump Life Insurance Services, Inc. ( Crump ). Note that the Assignor s right, title and interest maybe limited by the terms and conditions of the Assignor s contract or commission agreements with the insurance company and/or Crump. The compensation subject to assignment is a (MUST CHECK ONE): Percentage of Assignor s compensation: (please indicate % for all that apply, if left blank 100% will be assumed) Agent Rates Override Bonus All compensation Single Company (Carrier) Assignment (100% of all commissions due from business written with insurance carrier) Insurance Carrier:, or Single Policy or Policies Assignment (100% all commissions due on the policy or policies listed below) Insurance Carrier:. Policy # Name of Insured(s) [Attach a list if necessary] The Assignor further warrants the validity and sufficiency of the foregoing Assignment of Commissions, that no proceeding in bankruptcy or insolvency has been taken by or against the Assignor nor has any assignment for the benefit of creditors been made by the Assignor, and that there are no outstanding assessments, liens or levies because of unpaid taxes or other obligations of the Assignor. The Assignor further warrants that if a debt or chargeback is incurred prior to or at any time during which this Assignment of Commissions is in force, that this Assignment of Commissions does not release Assignor from any obligations to repay such debt or chargeback to Crump. The Assignor further warrants that this Assignment of Commissions is not for the purpose of circumventing insurance licensing laws or any other applicable laws or regulations. Payment made under this Assignment shall fully release the insurance company and Crump from all responsibility as to such commissions paid. IN WITNESS WHEREOF, the Assignor executes this Assignment of Commissions on: day of,. (Month) (Year) By: Assignor Signature (or signature of Officer if corporate agency)