Assurant Contracting & Appointment Checklist

Assurant Contracting & Appointment Checklist _____ Writing Agent/Producer Appointment Application _____ MGA Writing Agent/Producer Appointment Compensation Worksheet _____ General Agent/Agent Transfer Form _____ Agent Status and Commission Advice Form _____ NIA General Agent’s Agreement _____ Lead Agreement _____ Advance Guidelines _____ W-9 Form _____ Advance Agent’s E-mail Request Form _____ Copy of Current Insurance License _____ Proof of E & O Coverage – Recommended but not required! _____ State Appointment Fee(s)

Bay Insurance Marketing P.O. Box 1575

Palm Harbor, FL 34682 Phone: 800-878-9399, Fax: 800-878-9467

E-mail: [email protected]

A S S U R A N T HealthWriting Agent/Producer

Appointment Application for MGA'sForm MGA WA APR 09-05

AGENCY INFORMATION

1. MGA Name: MGA Business No.

2. GA Name: GA Business No.

INDIVIDUAL AGENT INFORMATION

4. Agenfs Name (Full legal name): Nickname (Optional):

5. Social Security Number: 6. Date of Birth:

~7. Resident Address: (Kequired)

STREET CITY / STATE / ZIP (9 DIGIT) PHONE

8. Business Address: (Optional)

STREET or P.O. BOX CITY / STATE / ZIP (9 DIGIT)

PHONE

E-MAIL

FAX

9. License Requirements - We require a copy of your personal health and life license for your resident state and each non-resident statein which you intend to operate. Fees associated with these appointments will be charged to your General Agency's commission accountwhere permitted. Please send copies of the appropriate licenses with this application.

10. Are you now or have you ever used any name other lhan shown above? FJ Yes FJ No If yes, list names, dates and

reason used:

11. Have you ever been appointed with Time Insurance Company (previously known as Fortis Insurance Company?)

FJ Yes FJ No If yes, list agent numbers:

12. Name of Errors and Omissions Carrier:

Provide details to any "YES" answers for questions 13 -15 on an attached sheet.13. Have you ever had a professional license refused, revoked or suspended; or, has disciplinary action been taken against

you by a regulatory agency? QYes Q No

14. Are you currently indebted to any insurance company or agency, or is there any dispute regarding your insuranceaccounts? FJ Yes FJ No

15. Have you ever pled guilty or no contest or been convicted of any violation of law other than minor traffic violations?FjYes DNo

Products are underwritten and issued by:

Time Insurance Company501 W MichiganMilwaukee, Wl 53201

limeInsurance

16. List . for past five years up to and including present date:FROM

VR)TO

(MO/YR) ADDRES CITY /STATE /ZIP PHONE

17 List all pmn1nv»« fnr past fivp ypars up to and including present date. Include dates, addresses, and positions:FROM

(MO / YR)TO

(MO / YR) ADDRESS CITY /STATE /ZIP PHONE

IMPORTANT INFORMATION

Fair Credit Act - I hereby authorize and request any present or former employer, police department, financial institution,insurance company, department of insurance or other persons having personal knowledge about me, to furnish bearer withany and all information in their possession regarding me in connection with an application for appointment as an insuranceagent. I am willing that a photocopy of this authorization be accepted with the same authority as the original, and Ispecifically waive any written notice from any present or former employer who may provide information based upon thisauthorized request. I understand this authorization is to be part of the written agent application which I signed and appliesto all companies, including any affiliated or import companies with which Assurant Health has a relationship, and productsI may sell through that application.Taxpayer Identification —Internal Revenue Code Section 6109 requires us to obtain your correct Federal TaxpayerIdentification Number (TIN). This information is required so that payments can be accurately reported to you on Form 1099-MISC. Failure to provide us with correct information may subject your account to backup withholding. If this occurs, we mustwithhold and pay to the Internal Revenue Service 31% of certain payments made to your account.Please Note:This application cannot be processed unless all questions have been answered and appropriate license copies are attached. Feesassociated with appointments will be charged to your commission account where permitted.

I represent that the answers given in this application are true and correct to the best of my knowledge and belief. Iunderstand that any misrepresentations or misstatements may result in immediate cancellation of this appointment andthe accompanying sales agreement. I grant full authorization to Time Insurance Company, Assurant Health andaffiliated companies to communicate with me via fax, e-mail or any other electronic means at the numbers/address I haveprovided herein or at any number/address I subsequently provide to Time Insurance Company. I understand that suchcommunications may qualify as advertisements under federal, state or local law and I consent to receive suchadvertisements. This authorization and permission shall remain effective until withdrawn by me in writing and receivedby Time Insurance Company.

AGENT'S SIGNATURE DATE MGA SIGNATURE

Company Use OnlyAppointment Date Agent Business

No.

Products are underwritten and issued by:Time Insurance Company501 W MichiganMilwaukee, Wl 53201 lime

Insurance

ASSURANT Health

Agent Name

MGA Writing Agent/Producer Appointment andCompensation Worksheet

Form Number TIC MGA ACT ACW (Rev. 09/05)

SSN

Name GA Agent Number

MGA's Name MGA Number

List the states in which you are requesting appointment for thisapplicant. Note: A legible copy of each state insurance license must be attached foreach state. Fees associated with these appointments will be charged to the GA's

count where permitted.

SELECT HOW AGENT IS TO BE PAID -Selection applies to ALL product lines^

j MGA or GA paysWriting Agent

[~| Company ContractCheck Through MGA

No Company Contract - don't complete Time Insurance Producer Sales AgreementCheck box to request Writing Agent Accounting and complete schedule options below.

Must complete Time Insurance Company Producer Sales Agreement, Form 25671

I I Resident |~1 Business

QSemi-Monthly [^Monthly

Select mailing address to be used for mailing statements and checksdirectly to agent. This address must be specified on Agent's application.

Commission Statement FrequencyPayment Frequency QWeekly DSemi-Monthly [^Monthly

^- Electronic Funds Transfer is available by completing the EFT form (required for weekly payment).

PRODUCT 8t COMPENSATION AUTHORIZATION - Select the products you are authorizing the Agent to sell by checking theappropriate box. You, the GA and MGA, must be authorized for the same products and be appointed in the same states where required by statelaw. Select the box which represents the desired commission schedule option for paid direct agents or if you requested writing agent accounting.

I [individualMedical

Schedule Option

Annualization

First Year D H D IRenewal D K D L

; ~] Yes I ~~\ No If yes, indicate limit

D J

Only available if the GA & MGA are annualized and the agent is company paid.

DshortTerm 6tStudent Select

CH Small Group

Schedule Option

Schedule Option

First Year D H Q IRenewal(Student Select) IT! H j i I

First Year D H Q IRenewal Q J D K

D JD JD J D Mn L

VoluntaryMartSchedule Option

[J 3 = Commission Level 1-3 based on productionLI 2 = Commission Level 1-2 based on productionI _ 1 1 ™ Commission Level 1 only regardless of productionSee producer chart for levels, rates and production requirements._

Commission Advance Q Yes | | NoOnly available if agent is company paid. If Yes, signed VoluntaryMart Commission Advance Addendum mustbe attached.

CompensationType

Newly Authorized Special Compensation

Non Level Compensation 1s1 year higher, lower renewalLevel Compensation = 1st year and renewal equal

Yes— - _ _ es xoA Writing Agent/Producer Appointment Application must be attached to process new agents/producers. I recommendappointing this agent per the above noted instructions.

GA Signature Date

MGA Signature Date

Products are underwritten and issued by:Time Insurance Company501 W MichiganMilwaukee, Wl 53201 lime

Insurance

ASSURANT HealthGeneral Agent / Agent Transfer Form

Form GA-AGT Transfer 09-05

Name of transferring General Agent or Agent_, am requesting a transfer

From

To

Name of current RSD, MGA, GA

Name of new RSD, MGA, GA

I understand that:• No transfer to another Time Insurance Company arrangement will be approved within 180 days of the initial

appointment or date the last transfer was effective.• This transfer will not go into effect until a date selected and approved by the Company which will follow the

receipt of proper notification by the current arrangement.• Any applications solicited prior to the date approved by the company will be credited to my current arrangement

Le. the "From" relationship listed above.• I understand and agree that any business written under my current arrangement will not be transferred or moved to

my new arrangement in any manner. This includes requests from policy owners for a new agent• I understand that my total compensation as a general agent or agent on individual major medical business will not

exceed %. (This includes any incentive bonus, reimbursements for leads or any other forms ofreimbursements).

Failure to comply with the rules stated above will be deemed a violation of the Company's policies and an act harmful to thebest interests of the Company. This will result in immediate termination for cause of my general agent or agentarrangement with Time Insurance Company and forfeiture of any remaining first year and/or renewal commissions.

Signature of Transferring General Agent/Agent Date Signed

Home Office Use only:Date Received

inLCSInitials Date Received

in Salesburials Notification

DateInitials Transfer Date Initials

Products are underwritten and issued by:

Time Insurance Company501 W MichiganMilwaukee, Wl 53201

limeInsurance

National Ins

~ce Agency

AGENTSTATUSANDC MMISSIONADVICENEW I HANGE

Date: SocialSecurity# I -----------------------------------------------

Agent's name ~------------------------------------------------(Last) (First) (Middle)

BusinessAd~s----------------------------------

(Street)

Homel

Addressl----------------------------------------------(Street)

----------------------------------------- --------------------------------------------------------(City, State, Zip) (City, State, Zip)

Bus. Phone ---------------------------------- Home Pnone --------------------------------------------

Fax Number ----------------------------

Email Address ~--------------------------------------------------

Resident License State -------------------------- I>OB --~--------------------------------------------------

Commission Level: --------------------------------------------------------

Immediate Manager: --------------------------------------------------------

Pay Mode: Issue Advance

Submit Advance paid daily, o~y with consistent weekly productionAs Earned

PLEASE CIRCLE C., GE REQUESTED:

AddressIPhone Management Commission Level

Approved by: ~-+_-----------------------

National Insurance Agency, 4040 Mct:wen, Suite 340, I>allas,TX 75244214-342-8588 Voice,1214-342-8699Fax

GENERALAGE~USCONTRACTThis Contract and the Commission Schedule{s) attached here to and apart of he,redf for all purposes referred to as this Contract, made on this - day of -_ 20- by and between National Insurance Agency, Inc.(NIA) of Dallas, TX (hereinafter referred to as Company) and General AgenUAgent(hereinafter referred to as General Agent or Agent). INDEPENDENT1CtNTRACTOR

It is expressly agreed that the relationship intended by this Contract between Gene I Agent and Company shall be that of an Independent Contractor only, and

that nothing contained here in shall be construed to create the relationship of e~PI yer and employee. This Contract or any benefit hereunder may not beassigned, transferred, or pledged by the General Agent.

MANNER OF CONDU NG BUSINESS

Agent's clientele may be developed by him by any lawful means. He shall select hi own hours and work days and i~ under no obligation to account to theCompany for his time. Company may hold sales meetings to acquaint the Agent w' h new products and sa~ ~chntqu.es for the benefit of .the Age~t. Howeverattendance at sales meetings will be optional and at the expense of the Agent. Age t sh~1Ibe free to eXercise his ~ Ju~gment as to the tme, ro~t.lne, pl~ce,

and method and manner he solicits insurance. Agent agrees to grant the Comp~n the nght of first refusal on all applications. Agent shall not solicit out Side thejurisdiction for which he is licensed or contrary to the laws or insurance regulatiClns of states where he operates.

The Company may from time to time make available to the Agent supplies, leads, ame lists, advertising matter and other material designe~ to assist Agent insoliciting business. All such material and other policy holder information, whethe~ p. st, current or prospective, a.cqu.ired by ~gent shall remain the sole propertyof the Company, shall not be duplicated and shall be retumed to the Company Wit In five(5) days after the termination of thiS Contract.

EXPEN ES

Agent shall be responsible for all expenses incurred in the production of insura~ce or the Company. Agent shall at his o~n expen~e fumis~ ~is ~wn ~eans oftransportation, office or place of business, advertisements, letters, letterhead, ClfCU ars, and any other relevant expenses Incurred In the solicitation of Insurancefor the Company.

Agent shall be responsible to Company for all loss or damage arising from busin L done by and entrusted to him and shall indemnify and hold Companyharmless from any and all expenses, costs, causes of action, loss or damages ~lting from fraudulent or unauthorized acts or omissions by Agent and anyagent(s) under contract with Company and assigned to Agent.

POWERS, DUTIES~RESPONSIBILITIESDuring the continuance of this Contract the Agent has the authority to:

A. Remit all applications for insurance to the Company for approval or rej

~

on and to collect only the initial premium payments due on such applications.B. Procure through agent(s) or personally through the Company,application for insurance written by the Company.C. When authorized by the Company and subject to Company approval, re its train and supervise agents.D. Agent shall have the duty of properly representing Company and develo ing his territory with diligence and in an ethical manner, and the Agent

agrees to conform to the rules, regulations, practices and minimum p~od ction requirements of Company.E. Agent shall be responsible to Company for all monies and securities f ived by him for Company and shall hold such in trust separate from all other

funds and securities, and promptly remit same to Company.F. Company reserves the right at any time to terminate the contract of any

~ent or agents assigned to him and appointed by Company.

G. The Agent shall not insert or authorize the insertion of any advertising m tter bearing the Company's names in any publication, issue or distribute, orauthorize the issuance or distribution of any circular or paper on behalf f the Company, without first submitting said advertising matter in writing toCompany and receiving prior written approval of Company.

COMMIS IONSCompany agrees to pay the Agent commission on business written by Agent or ~n agents assigned to him by the Company on premiums actually received andEamed by the Insurance Carrier in accordance with the Commission Schedule(s) ttached hereto. In the event Insurance Carrier shall, either during thecontinuance of this Contract or after its termination, refund premiums under any p licy to an Insured: Agent shall immediately repay to Company the amount ofany commission paid him or his agent(s) on the premium. Commissions will be c ited or paid only if paid by the Insurance Carrier.A. All commissions shall be calculated only on premium actually received the Insurance Company. Commissions will be calculated only on those

Premiums paid by or on behalf of the insured. No commissions shall be aid on interest, or on premium waived or commuted by reason of death,

disability Or exercise of policy options. IB. Company at any time while this Contract is in force or after its terminati may set off against any claims by Agent for commissions or other monies

accruing to the account of the Agent under the terms of this Contract an debts, liabilities or obligations of the Agent to the Company. If any Agent hasagents assigned under the Agent, Agent is responsible for all indebtedn ss which any agent assigned to Agent owes to Company. At Company's soleDiscretion Agent's account will be credited with commissions from and ited for all charges against such agents account. Agent further agrees thatany indebtedness now or here after owing to the Company or its affilia shall be secured by a first fien against the commission or any other moniespayable To Agent under this Contract and any other contract Agent ma have with the Company or its affiliates.

C. All amounts owed to Company or its affiliat~ by A~ent shall become jdu and payable imm~iately upon notice to the Agent. At the sole discretion ofthe Company demand may not be made until that Indebtedness exceed any amounts of projected earned commissions for the next six (6) monthsas determined solely by the Company. '

D. The right to receive commissions shall automatically terminate upon te

~

ination of this Contract except as provided here in. Payment of commissions

~p~n ~ermination of th~ Contract. will be vested immediat~I~, subject 1'10 ever, to the Company's right to set off asset within this Contract, thelimitations and exceptions descnbed be low and the provIsions of thelL n Agreement section of this contract. The right to receive vestedCommissions, if any, shall immediately cease or be modified Without.~o Ice if:(1) This Contract is terminated for cause or for any violations ~f a y of the provisions or agreements of the Contract.(2) In any month following termination the amount of vested co\TI ission paid under this contract is less than $50.00 or the number of in-force

policies is less than 25.

(3) If a debit balance exi~ts and. is not repaid with in ~O ~ays folio 'ng contract termination the vesting provision is modified to: a) One calendaryear .or Longer NIAwill credit your account commISSions for a twelve-month period after termination for each calendar year your contractwas In for~; b) .Iess than on~k7ndar year, commissions ~I immediately terminate. However, notwithstanding your account will continue!o be credited First Yea~ commlsslon~ to the extent. o~your

E

~ ebtedness. In the event your First Year Commissions do not satisfy yourIndebtedness, the remainder of your Indebtedness IS Imme I ely due and payable without demand' or c) After three (3) full calendar yearsall commissions will be credited to your account for the pre i m payment life of the policy. '

E. At the option of the Company, payment of commissions will be held in a yance for 30 days after termination to determine the existence of any sumswhich are to be set off against commissions

This Contract terminates due to death or permanent disability of the A~e~t. Commissions will be credited for (5) years there after or as set out in Dabove, whichever is greater. Eligible commissions will be payable to !tie ~urviving spouse. If no surviving spouse then such eligible commissions shallbe paid to the Executors or Administrators of the Agents Estate.

After termination Agents Account willbe credited ninety-seven percent (!V%) of the eamed commissions. The remaining three percent (3%) will bepaid to NIA as an administrative fee.

H. The Company reserves the right to alter, increase, decrease, modify, or with draw the Commission Schedule and/or Loan Provisions of this Contractat any time.

LOAN AGR

~MENT

If Agent elects, Company may make periodic loans to Agent against future cred~~ commissions on applications written and submitted to the Company byAgent or any agents assigned to Agent. Such loans shall be made in lieu of payme t of credited commission as provided in the Commission Schedule.A. Such loan shall be a percentage of annualized insurance premium onlpr uction submitted on completed applications, the percentage loaned will be

determined at the sole discretion of the Company.8. Any loan proceeds shall be reduced by the amount of chargeback's to A$,ent'saccount from any source.C. The unpaid principal balance shall bear interest at a rate of one and a'h

~

percent per month.

INDEBTEDNESS Of ENERAL AGENTAny indebtedness owed by the General Agent to the Company shall be paid upQn otice to the General Agent. In addition to the provisions of paragraphDeportment all indebtedness of the General Agent to Company shall be secured b a first lien on any commission or renewal commissions due or to becomeDue to the General Agent. The Company may at any time offset against all comm' ion accrued or to be accrued to the General Agent, any debt due from the

General Agent to the Company, whether now existing or hereafter arising. In th~ e ent any indebtedness is placed in the hands of a collection agency orattomey, or both, Company shall been titled to recover, reasonable collection a~d ttomey's fees.

F.

G.

For the purposes of this paragraph, an "agent" shall be any agent of Company on hom General Agent receives an over ride commission, or who is assigned to

General Agent and becomes a part of General Agents hierarchy, irrespective oflth number of levels of agents under General Agent. General Agent shall befully responsible for any indebtedness (sometimes referred to as an 'agent's de~it alance') of an agent, and does here by guarantee payment of any and allindebtedness of an agent. Upon payment and discharge of said indebtedness in I, General Agent shall be subrogated to Company's rights against agent, andmay proceed directly against the agent without the joinder of CQmpany. General A ent hereby approves any advances or loans which Company makes to anAgent, and Company shall not be obligated to obtain General Agent's approval pf ny specific loan or advance.

DEPOR' ENT

Should the Agent at any time, either before or after termination of this Contract, ng fully with hold any funds belonging to any applicant for insurance, a policyHolder or the Company; or should the Agent induce any policy holder to lapse, reli quish or surrender a policy with the Company; or should Agent be in defaultunder, or fail to comply with any provision, covenant, representation or warrantyl' ntained in this Contract or any other Contract agreement, or in any documentor instrument related there to, between the Agent and the Company; or should the gent fail to comply with any State insurance laws or regulations, or Federallaws or regulations under which he or it is licensed or is otherwise subject; then th Agent shall immediately forfeit his or its right to receive any commissions orany other compensation due or to become due, whether vested or otherwise, und this Contract or any other agreement with the Company.

ERRORS ANd MMISSIONS

For the protection of Agent and the Company, Agent shall carry an Errors and Om sions liability policy of not less than $1,000,000 per occurrence.

JURISDICTION, I Wand VENUEThis Contract is subject to jurisdiction of the courts of the State of Texas and is to e interpreted in accordance with the laws of the State of Texas. Venue forany action, suit or other proceeding, ineluding non-contract disputes, shall be exel sively in Dallas County, Texas. Agent shall agree to the jurisdiction of thecourts of Texas and waive any other venue.

ADDITIONAU P OVISIONS

This Contract is personal and not transferable. Any assignment, transfer, or sale 0 this Contract or any right to interest here in, without prior written consent ofCompany, shall not be valid or in any way binding upon Company.

The use of the masculine gender shall inelude the feminine gender and the uselof he singular shall include the plural where appropriate.

This Contract takes effect on the date and year the contract is executed by an 0 r of the Company.TERMIN TlON

This Contract may be terminated at the will of either party here to, for any reasdn ith or without cause, at any time upon actual notice, written or oral. ThisContract will automatically terminate if Agent fails to submit new business in any1 0 day period to NIA. Cancellations or loss of license shall automaticallyterminate this Contract. Agent agrees not to contract with insurance carriers repre nted by Company for one year. Company may obtain an injunction ortemporary restraining order to enforce this provision. I

Loan Agreement - I hereby elect to receive loans when made available by the COrT.Ipanyfor Health ***u Life ***u I do not elect to receive loans

IN WITNESS WHEREOF, this Contract has been signed by the parties hereto. p

------------------------------------------ ------- ,---------Signatureof General Agent Company Rev 2/19104

National Insurance Agency, Inc. 40401McEwen,Suite 340, Dallas, TX 75244888-243-5026voicl!,1214-342-8699fax

Suite3~0Dallas, TX 175244

ment

This Agreement, executed in duplicate originals, this the day of between NationalInsuranceAgency(NIA), 4040McEwenDr.Suite340of Dallas,Tex s, hereinaftercalledthe "Manager",and

,Address - of StateZip hereinaftercalledtheMAgenf, hereinit is mutuallyagreedas follows:

1. Supply Leads. Manager agrees to use their best efforts t supply Agent with leads for use by Agent in the solicitation ofinsurance policies in accordance with the Agent's contra with NIA.

2. Exclusive Use. Agent agrees to use the leads furni~h d to Agent exclusively in the solicitation of applications forinsurance policies for NIA.

3. Responsibility for Leads. Agent agrees to accept the respo sibility to account to Manager for all leads received.4. Unauthorized Use of Leads. In the event that Agent db not use the leads exclusively for the intended use in Section

Two (Exclusive Use) above or if the Agent does not pro rty account for the leads supplied to him according to SectionThree ("'Responsibility for leads) above. Agent herepy agrees to pay for those leads not used according to theaforementioned Sections immediately upon demand in ca h.

5. Lien on Account. Agent hereby grants Manager a lien n Agent's account with NIA. Said lien shall be subordinate tothat of NIA and shall be only in an amount equal to any onies due Manager for leads not used according to SectionsTwo and Three (Exclusive Use) and (Responsibility for Ie ds) of this Agreement with interest here on at the rate of onepercent (1.5%) per month on the balance due.

6. Authorityto charge Account. In the event the Agent dO,s not remit to the Manager the monies due underThis Agreement, Agent hereby agrees that the monies o~ed to the Manager will be debited to the Agent's account wit~NIA.

7. Lead Cost. Lead cost will be charged at NIA's cost Any;xcess monies collected from the advanced Percentage rate;allocated for lead procurement will be applied to your Ag nt Account Statement (Per Section 9 - Policy Form Advancec- on the Advance Commission Addendum) The Lead de it and the Advance debit must be satisfied before the agen1receives any earned commission.

8. Hold Hannless. Agent agrees to hold NIA, its officers, Idirectors and employees, harmless for all acts or omissionspertaining to the performance of the Agreement

){----------------------------------------------------------------AgenfsSignature

){----------------------------------------------------------------Agenfs Name(PRINT)

){----------------------------------------------------------------

Officer of National Insurance Agency

){----------------Date

---------

*Agreeing to be Individually Bound Hereby:

(This contract is effective only when signed by an officer of Natiof\lallnsurance Agency at its office in Dallas, Texas.)

Rev3105

All Reouirements must be met new business to be advanced.

Numbers of Months Advanced are dePlacement/taken rate, frequen

ined by agents production volume,turn in and credit worthiness.

Agents eligible forla~vance on submitMUST maintain an averae!e .f 1 application per week.

Agents with Vector debits or adverse credit willlb~ reviewed on a case by case basis for advancesAdvances are loans made on ~oqunissionable premium only.

1. The followingconditionson any application will result in

{

dommission advanced uoon issue:

* Any applicant 45 years of age or older with no prior coverag* Any applicant with 2 or more co-morbidity factors including o~acco usage, high blood pressure, elevated cholesterol and ratable

build

~

Any applicant60 years of age or olderApplications with out complete Doctor Information for each pJblicantHigh blood pressure with high cholesterolHeart murmurs on medication or beta-blockers

tApplications that are held more than two weeks by agent fro <fatesigned.Height/weight chart must be used in the "quote"Personal or controlled business (will be paid as earned).Uninsurable occupations or avocations.Non-USA residents here on Visa.

iMultiple or severe impairments that would result in 2 or mor 4clusion waiversRate-ups of over25%that have not been collected at the time f saleIf20% surcharge is not collected for high blood pressure.Allergies, Asthma, ADD and depression will be reviewed onlcl$e-by-case basis for advance.Applications previously declined by another carrier.

**************

2. Agents must service their business with signed Riders and fo~ow-up, etc.

Any agent who does not service their business or NlA receives com

,

llJ#aints regarding customer service from applicants will not continueto be advanced and will be subject to termination

3. Every application must be submitted with a completed Transq.ittal Form and a Quote Sheet.The quote must match the benefits on the application and the chedk ~annot be more than $20 short.

4. Every application must be completed "fully" to be conside l

;Efor an advance. Every question must be answered, including social

security numbers, health questions, etc. Ifa health question is anst d "yes" it must be fully explained with dates, treatments, names ofmedications, the degree of recovery and COMPLETE doctotS

;L

inti tion.

EACH PERSONLISTED ON THEAPPLICATIONMUST A DOCTOR,ADDRESS,DATEAND REASON F OR THELAST VISIT. APPLICATIONS WITH VAGUE OR INCOMP ~ INFORMATION WILL NOT BE ADVANCED ON SUBMIT.

5. The primary insured and the spouse must s12nevery apPIi

~1 tipn. The primary insured must sign all accompanying forms and

association applications. (The spouse is only signing the applicati n fts the spouse; no other forms should be signed by the spouse.) Theinsured and spouse signature cannot be signed by the same perso .

-8588 voice, 214-3423-8699 fax

I

6.Any application mayor may not be advanced subject to undfIivriting guidelines. *Applications with multiple medications, questionable health conditiqns or applications requiringMedical records will be advanced upon issue.

* It is your responsibility to read the under writing guidelines. Foria fomplete under writing guide, visit our website at www.ma.biz.

7. No coverage will be offered to any applicant with any diagn~s~ic testing or surgery pending,

8. Methods of Payment will be advanced as follows:

. Monthlybankdraft

. Quarterly premiums will be advanced 3 months'

. Semi Annual premiums will be advanced 3 mont~s on submit/3monthson issue'

. NO ADVANCE WILL BE GIVEN ONMON1THty DIRECT BILL

Agent Acknowledgement:

Agent agrees that he/she has read the Producers Underwriting Gu~d

To be advanced on submit is a privilege given only to agents who sefvice their business and write good business. Advances on submitare "at will" ofNIA and may be changed or modified at any time.

I have read, understand and agree to all of the NIA Advan£e Guidelines terms and conditions.

------------------------------------------------------------------ --------------------------------------------------

Agent's Signature Date

National Insurance Agency-4040 McEwen, Suite340, DI!lI~ TX 75244, 214-342-8588 voice, 214-3423-8699 tax

Give form to therequester. Do notsend to the IRS.

Form W-9 Request for TaxpayerIdentification Number and Certification(Rev. January 2003)

Department of the TreasuryInternal Revenue Service

Name

List account number(s) here (optional)

Address (number, street, and apt. or suite no.)

City, state, and ZIP code

Pri

nt o

r ty

pe

See

Sp

ecifi

c In

stru

ctio

ns o

n p

age

2.

Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN).However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions onpage 3. For other entities, it is your employer identification number (EIN). If you do not have a number,see How to get a TIN on page 3.

Social security number

––or

Requester’s name and address (optional)

Employer identification numberNote: If the account is in more than one name, see the chart on page 4 for guidelines on whose numberto enter. –

Certification

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

I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the InternalRevenue 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 hasnotified me that I am no longer subject to backup withholding, and

2.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backupwithholding 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 retirementarrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you mustprovide your correct TIN. (See the instructions on page 4.)

SignHere

Signature ofU.S. person � Date �

Purpose of Form

Form W-9 (Rev. 1-2003)

Part I

Part II

Business name, if different from above

Cat. No. 10231X

Check appropriate box:

Under penalties of perjury, I certify that:

U.S. person. Use Form W-9 only if you are a U.S. person(including a resident alien), to provide your correct TIN to theperson requesting it (the requester) and, when applicable, to:

1. Certify that the TIN you are giving is correct (or you arewaiting 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 aU.S. exempt payee.

Foreign person. If you are a foreign person, use theappropriate Form W-8 (see Pub. 515, Withholding of Tax onNonresident Aliens and Foreign Entities).

3. I am a U.S. person (including a U.S. resident alien).

A person who is required to file an information return withthe IRS, must obtain your correct taxpayer identificationnumber (TIN) to report, for example, income paid to you, realestate transactions, mortgage interest you paid, acquisitionor abandonment of secured property, cancellation of debt, orcontributions you made to an IRA.

Individual/Sole proprietor Corporation Partnership Other �

Exempt from backupwithholding

Note: If a requester gives you a form other than Form W-9to request your TIN, you must use the requester’s form if it issubstantially similar to this Form W-9.

Nonresident alien who becomes a resident alien.Generally, only a nonresident alien individual may use theterms of a tax treaty to reduce or eliminate U.S. tax oncertain types of income. However, most tax treaties contain aprovision known as a “saving clause.” Exceptions specifiedin the saving clause may permit an exemption from tax tocontinue for certain types of income even after the recipienthas otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on anexception contained in the saving clause of a tax treaty toclaim an exemption from U.S. tax on certain types of income,you must attach a statement that specifies the following fiveitems:

1. The treaty country. Generally, this must be the sametreaty under which you claimed exemption from tax as anonresident alien.

2. The treaty article addressing the income.3. The article number (or location) in the tax treaty that

contains the saving clause and its exceptions.4. The type and amount of income that qualifies for the

exemption from tax.5. Sufficient facts to justify the exemption from tax under

the terms of the treaty article.

Attention: NIA Advance Agents To be eligible to receive advance commissions, it is required that we have your e-mail address and fax number. Our goal is to communicate NIA updates, changes and application information in a quick and timely manner. Agent Name: _______________________________________ State: _____________________________________________ E-mail Address: _____________________________________ Dedicated Fax Number:_______________________________ Thank you!