Lines : Type of Entity: Individual Partnership Corporation Other

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1 Name of Agency: Peninsula Excess Insurance Brokers, Inc. (PenEx) works through as much as possible for maximum efficiency. Please answer the following questions so that we can serve your agency better. Address: Phone Number: Fax Number: Principals: FEIN Number: Website: Total Premium Volume Commercial Lines : Type of Entity: Individual Partnership Corporation Other Addresses of Personnel:

2 Producer/Broker Agreement Agreement between Peninsula Excess Insurance Brokers, Inc. (PenEx) 1055 Westlakes Drive, Suite 300 Berwyn, PA And Producer/Broker Producer/Broker wishes to place business through PenEx in accordance with applicable laws and regulations; and WHEREAS, PenEx is willing to offer its facilities to Producer/Broker for placement of insurance by admitted and/or nonadmitted carriers, all the foregoing in accordance with the laws and regulations pertaining thereto; NOW THEREFORE, in consideration of the mutual covenants and agreements hereinafter expressed, the parties hereto, intending to be legally bound, agree as follow: 1. Licensing: Producer/Broker represents and warrants that it is properly licensed in accordance with the insurance laws of any state where the insured is located or where Producer/Broker conducts business. 2. Premiums: All premiums, taxes and fees collected from insured s and which are to be paid to PenEx shall be held by Producer/Broker in a fiduciary capacity/trust Account and in accordance with applicable state law and shall not be co-mingled with Producer/Broker s other funds. Producer/Broker shall remit all premiums, taxes and fees to PenEx no later than 5 days after coverage is bound on an account. PenEx reserves the right to make specific exceptions to the above premium payment terms when, in the sole and exclusive judgment of PenEx, circumstances or conditions require earlier payment of a transaction, in which case Producer/Broker will be notified of the revised payment terms on the PenEx quote/indication coversheet.

3 3. Payments: Insurance issued or bound by PenEx on behalf of the Producer/Broker is not subject to flat cancellation. Producer/Broker hereby guarantees the payment of all premiums, taxes and fees due PenEx on any insurance bound or written hereunder, whether or not Producer/Broker to any insured or others for whom policies are being issued shall be at Producer/Broker s sole risk. If the Producer/Broker does not make payment to PenEx when due, Producer/Broker understands that PenEx or its companies, without limitation of its other remedies, reserves the right to cancel polices for non-payment of premium. Nothing herein shall limit the right of PenEx or companies to cancel any contract of insurance issued hereunder in accordance with any other cancellation provisions of such contract. 4. Audits: If an insured is audited and an additional premium is required as a result of such audit, Producer/Broker agrees to use its reasonable efforts to collect such premiums from the insured. If such premiums are uncollected and the unpaid account is returned within twenty (20) days after receipt by Producer/Broker, with evidence that Producer/Broker has made a reasonable and responsible effort to collect said premiums and if the insurance carrier issuing the policy agrees to undertake direct collection efforts thereafter, PenEx shall return said accounts to the carrier for collection. Producer/Broker shall receive no commission on audited policies returned for direct collection. Producer/Broker shall have the right, as long as not indebted to PenEx, to deduct agreed upon commissions on each policy of insurance prior to remitting the net premium due to PenEx. 5. Claims: Producer/Broker agrees to report immediately to PenEx, with full details, any fact, occurrence or incident that may result in a loss or claim. Producer/Broker shall forward all documents and cooperate fully with PenEx and/or its insurance carriers in the investigation and adjustment of any claim, as requested. 6. Insurance: Producer/Broker agrees to maintain errors and omissions coverage for itself and those for whom it is responsible with limits of at least $1,000,000 and provide PenEx with a certificate of insurance, indicating such coverage annually. 7. Responsibility: PenEx assumes no responsibility toward any policyholder, insured or sub-producer with regard to the adequacy, amount, scope or form of coverage through PenEx.

4 8. Advertising: Producer/Broker shall not advertise in any way the name of PenEx or any Company or Underwriter represented by PenEx without the prior written consent of PenEx. 9. Indemnification: Each party will defend, indemnify and save harmless the other party against any and all claims, suits, liabilities, losses, etc. arising out of or in any way resulting from the negligence or failure to perform its duties hereunder by the indemnifying party. 10. Binding Coverage: It is understood that Producer/Broker is an independent contractor and shall have no authority to write any insurance or bind any risk for PenEx or any Company or Underwriter represented by PenEx. Producer/Broker is not the agent of PenEx or any company or underwriter represented by PenEx. PenEx does not bind coverage until Producer/Broker receives written confirmation from the company Underwriter. 11. Ownership: Both parties recognize the independent ownership by Producer/Broker of the insurance business covered by this Agreement. In the event of termination of this Agreement, the Producer/Broker, having promptly accounted for and paid all premiums for which it may be liable, the Producer/Broker s records, use, and control of expirations shall remain the property of the Producer/Broker and be left in its undisputed possession; otherwise, the records, use, and control of expirations shall be vested exclusively in PenEx. If said producer terminates relationship with PenEx, and moves book of business direct with carrier, 180 days advance notice will be given to PenEx in writing advising of termination. 12. Taxes: Producer/Broker agrees to file at Producer/Brokers expense, all necessary affidavits and collect all State or local premium taxes and to pay the same promptly to the respective taxing authorities on all insurance placed through PenEx, in accordance with the laws applicable to the State of licensing unless PenEx agrees to pay and process surplus lines tax. 13. Construction: This agreement contains the entire agreement of the parties hereto with respect to the matters contained herein. No supplement, modification, or amendment to this agreement shall be binding unless executed in writing by all of the parties.

5 14. Entire Agreement: This agreement contains the entire agreement of the parties hereto with respect to the matters contained herein. No supplement, modification, or amendment to this agreement shall be binding unless executed in writing by all of the parties. 15. Assignment: This agreement may not be assigned by either party, by operation of law or otherwise without prior written consent of the other party. Signed on this day of, Accepted for Peninsula Excess Insurance Brokers, Inc. (PenEx) Signature Print Name Title Signature- PenEx Print Name Title Agency Name Telephone Number Fax Number Please attach all license information to this agreement (Resident, Non-Resident and Surplus Lines Licenses) and a copy of your Errors and Omissions declarations page or certificate of insurance evidencing coverage.