STREET ADDRESS: 3250 GREY HAWK CT., CARLSBAD, CA PHONE: *FAX:

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1 Dear Producer: SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) looks forward to doing business with your agency and beginning a good working relationship. CHECKLIST Legible copy of your current broker s license Legible copy of your broker s bond (if applicable) Copy of your current E & O Policy declaration page Completed brokerage contract Completed Producer Questionnaire Completed W-9 Form Please send the completed information to: SIS Insurance Services Attention Marketing 3250 Grey Hawk Ct. Carlsbad, CA Fax Pg. 1

2 PRODUCER QUESTIONNAIRE PAGE 1 OF 2 Legal Agency Name: DBA: Mailing Address: City: State: Zip: Street Address: Phone Number: ( ) --- Fax Number: ( ) --- Agency is a: Partnership Sole Proprietorship Corporation S-Corporation Date Agency Established: Federal ID or Sec. No.: Name and addresses of all persons having an ownership interest in agency. Please attach additional sheets if necessary. Name of Owner /Principal Home Address: City: State: Zip: Total Number of employees: Number of Producers: Key Employees: Name Title Pg. 2

3 SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) PRODUCER QUESTIONNAIRE PAGE 2 OF 2 Have you or anyone in your agency been sued concerning insurance related activities? Yes No If yes, please explain on a separate sheet and attach this form. Have you, your employees, or your agency been disciplined by any State Agency or Department of Insurance? Yes No If yes, please explain on a separate sheet and attach this form. Has any Error & Omission claims been made in the most recent five years against your agency, officers, partners or owners? Yes No If yes, please explain on a separate sheet and attach this form. Financial Information: Bank Name: Mailing Address: City State Zip Trust Account #: Average Balance: $ Do you have overdraft protection: Yes No Please list companies and MGAs you place business with in order of premium volume: Carrier/MGA: Annual Premium: Loss Ratio: % % % % It is agreed that the statements on this application or any material submitted herewith are true and accurate representation of the applicant and they shall be deemed material to the acceptance of risk(s) from the brokerage by SIS Insurance Services Name (Please print): Title: Must be signed by agency principal Signature: Date:

4 This agreement, made and entered into SIS, and Producer: Mailing Address: Hereinafter called Broker LIMITED PRODUCER AGREEMENT 1. Broker shall have no authority to bind any coverage s on new or renewal business or claim hereunder, or make any changes in terms and conditions of any policy of insurance. 2. Broker shall have no authority to issue a binder in the name of SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) or any company represented by SIS. 3. In the event an unauthorized binder is issued by the broker thru SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) or company(s) represented by SIS suffers loss, producer agrees to indemnify, hold harmless and defend SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) and/or company against any judgment or settlement and for all loss and expense, including attorney fees and investigation, incurred by the company(s) or by SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) in the payment or defense or claim or loss resulting from said unauthorized binder. 4. SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) will allow producer commissions at such rates as agreed from time to time by the parties hereto. In the event of return premium becoming due for any reason whatsoever, producer shall refund commission to SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) at the same rate at which commission was originally allowed. It is agreed that there will be no commission paid on any policy fees, taxes or other fees added to the policy. 5. Producer agrees that no flat cancellation shall be allowed. Broker will pay to SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS), any and all open accounts, accounts stated or other indebtedness arising out of or relating to policies of insurance under this agreement. Broker further guarantees to pay earned premiums (including minimum premiums and collected audit premium) and all other fees and charges for the time coverage is in force and effect on any and all insurance policies written through facilities of SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS). Broker shall be responsible for arranging for the return to the return to the insured of unearned premium and unearned commissions that belong to the insured. Broker shall remit all payments to SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Pg. 4

5 Services (SIS) within (10) ten days of broker s receipt of such payment. Broker shall hold all payments received from insured in trust until payments are transmitted to SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS). No payment accepted or received by broker shall be deemed paid to SIS until such payment shall be received in hand by SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS). Any violation of the foregoing shall be considered a breach of the broker s fiduciary responsibilities and obligations to SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) and its insurance companies and MGA(s). Broker recognizes that any violation of the terms of this paragraph shall be sufficient cause for rescission of this agreement. 6. The producer may submit business from the state of California. It is agreed that within said California, the producer shall be free to exercise his judgment as to the person solicited and the time, manner, means and places of solicitations, and SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) shall not be responsible for any expenses incurred by the producer in such solicitations, or any brokerage expense. 7. The producer is not an agent; employee or representative of SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) or any company(s) represented by SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS). No act of the producer shall be binding on SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) or its company(s). The producer represents that he/she is duty authorized under the laws of the state of California. The producer shall be transacting business on behalf of his/her client and not SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS). 8. SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) will use its efforts to give the producer reasonable advance notice of the expiration of all policies, but failure to provide such notice shall not render SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) liable. In the event that the producer not being in default and therefore promptly accounting for and paying all accounts for which he/she may be liable, the producer(s) records and use and control of expirations(s) shall be deemed the property of the producer and left in his/her undisputed possession and control. 9. Producer agrees to indemnify and hold harmless the SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) any of its employees and agents, along with any of its underwriting companies, claim adjusting companies or insurance companies from and against any and all claims arising out of or relating to any alleged act or alleged failure to act on the producer which results in any claim, demand, action or cause of action against SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) or its underwriting companies, claim adjusting companies or insurance companies whether or not said claim, demand, action or cause of action be meritorious. Producer agrees promptly notify SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) of any claim, demand, action or cause of action in which the SafeBuilt Pg. 5

6 Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) or any of its underwriting companies, claim adjusting companies or insurance companies from any and all loss, expense, demand, action or cause of action, settlement or judgment including expenses of investigators, expert witnesses, court costs, attorney fees of the like arising from or relating to any alleged failure to act on the part of the producer whether or not said claim, demand, action or cause of action be meritorious. 10. Producer agrees to indemnify and hold SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) its shareholders, directors and employees harmless against and in respect of any and all claims, demands, actions, liability, losses, damages, judgments, costs and expenses, including without limitation, attorneys fees, disbursements and court costs, made or instituted against, or incurred by SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) its shareholders, directors and employees which arise directly or indirectly out of any act or omission of the producer, or its employees or representatives. 11. Producer in placing business under this agreement recognizes that broker is a representative of the insured and is not acting as an agent or representative of SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) or its insurance companies, or claim adjusting companies. 12. SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) or the insurance company shall have no responsibility for any expense incurred by broker no matter howsoever arising. 13. Producer shall abide by the California Fair Claims Settlement Practices Regulations when handling claims. 14. In the event of any dispute arising between the parties relating to this agreement, it is agreed that the only venue for litigation shall be Los Angeles County, California. It is also agreed that the prevailing party in any such litigation shall be entitled to recover all reasonable legal and other expenses arising out of such action. 15. Producer agrees that broker will provide each insured with an explanation of the terms and provisions of the policy of insurance including, but not limited to coverage being afforded and also exclusions contained with the policy of insurance. 16. Producer agrees to keep in full force and effect an Errors and Omissions insurance policy with limits no less than $1,000,000 during the full term of this agreement and if requested Pg. 6

7 will send a copy of the policies to SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS). 17. The provisions of this agreement are severable, and if any one or more provisions may be determined to be judicially unenforceable, in whole part, the remaining provisions shall nonetheless be binding and enforceable. 18. This agreement supersedes and replaces any and all previous agreements and shall be effective as of the date hereafter written and shall remain in force and effect to and until cancellation which may be effectuated by either party giving to the other written notice of cancellation which shall be mailed to the party at the address first herein above written of such other address as may from ti me to time in writing be specified by a party to this agreement for the giving of notice. Cancellation of this agreement will become effective after the date of mailing and any such cancellation shall comply with the laws of the State where the broker s license is issued. The parties hereto extending to be legally bound, have affixed their hands this day of PRODUCER: SAFEBUILT INSURANCE SERVICES, INC.: DBA Structural Insurance Services 3250 Grey Hawk Ct. Carlsbad, CA IRS # SIGNATURE: POSITION: SIGNATURE: POSITION: Pg. 7

8 Form W-9 (Rev. October 2007) 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. Print or type See Specific Instructions on page 2. Business name, if different from above Check appropriate box: Individual/Sole proprietor Corporation Partnership Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) Other (see instructions) Address (number, street, and apt. or suite no.) City, state, and ZIP code List account number(s) here (optional) Exempt payee Requester s name and address (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 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 get 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 or 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 Date 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 ). 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. The person who gives Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States is in the following cases: The U.S. owner of a disregarded entity and not the entity, Cat. No X Form W-9 (Rev )

CHECKLIST. SIS Insurance Services 3250 Grey Hawk Ct. Carlsbad, CA 92010

CHECKLIST. SIS Insurance Services 3250 Grey Hawk Ct. Carlsbad, CA 92010 Dear Producer: SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) looks forward to doing business with your agency and beginning a good working relationship. CHECKLIST Legible

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