Everest/WFGIA New Agent Contracting Set Up Sheet

Transcription

1 Everest/WFGIA New Agent Contracting Set Up Sheet WFG Code # Agent s Name: Address: Apt./Suite No.: Phone Number: Address: Checklist: Completed Producer History Sheet (9511) Contract (3357) signed by Agent Signed Consumer Report Notification and Authorization (Form 9127) Signed Compliance Guidelines Statement of Understanding (Form 9528-C) Anti-Money Laundering (AML) course must have been completed within the last two years Comments: For Occidental Home Office Only: Hierarchy #: Products: Golden Solution & Family Solution OL8900-EV/WFGOL (4/14)

2 PRODUCER HISTORY 1. WRITING AGREEMENT Please Print in Black Ink Agency/Agent Sex Date of Birth City, State of Birth (PR Only) Corporate Contracting Information: Corporate Name (as printed on insurance license) Your position in corporation (must be a principal) Residence Address City, State, Zip County Business Address City, State, Zip Send all mail to: Business Home Residence Phone Business Phone Address Agency Tax Payer Identification Number Agent Social Security Number Drivers License (State & Number) Resident License State Resident License No. Non-Resident License States 2. CONTRACTING QUESTIONS a. Have you ever been appointed with Occidental Life Insurance Company of North Carolina?... Yes No b. To your knowledge, are you presently the subject of any investigation or proceeding by any insurance, securities, or commodities agency, jurisdiction, or organization?... Yes No c. Are you now or have you ever been a defendant in any litigation alleging the violation of any agreement with or provision of any insurance securities or commodities law or regulation?... Yes No d. Has any insurance company within the past 10 years canceled any contract with you for any reason other than the nonproduction of business or at your request?... Yes No e. Have you ever been convicted of a misdemeanor (other than a minor traffic offense), a felony or violation of 18 USC 1033? Yes No If yes, list: Date County State If a 1033 violation, attach consent letter from appropriate Department of Insurance. f. Do you have any judgments or tax liens, bad debts, or collections items of any kind against you?... Yes No g. Are you indebted to any insurance company, general agent, or manager (including debit balances)?... Yes No h. Have you filed for bankruptcy under any bankruptcy act in the last 10 years?... Yes No i. During the past 10 years, has any commissioner or any Department of Insurance or any stock exchange suspended, canceled, or revoked any license issued to you, fined you, or ever refused to issue or renew any such license for any reason whatsoever?... Yes No j. Have you ever had any complaints, including but not limited to complaints with an Insurance Department or Insurance Company, filed against you?... Yes No k. If you currently hold NASD license(s), provide series number(s) l. Have you taken the Anti-Money Laundering (AML) training course through: Our Company Other Company LIMRA Date Taken: / /... Yes No m m / d d / y y If no, you must take the Company online AML training course located on the Company website. (See AML Course Access Instructions in your Contracting Kit.) DO NOT SEND IN YOUR CONTRACT WITHOUT OUR COMPANY AML COMPLETION CERTIFICATION. (THE EXCEPTION TO THIS REQUIREMENT IS THAT IF YOU HAVE TAKEN THE LIMRA AML COURSE, YOU MAY SEND IN YOUR CONTRACT AND THE COMPANY WILL VERIFY YOUR COMPLETION OF THE AML COURSE). 3. EXPLANATION - Please explain any Yes answers here; attach additional sheets if necessary. This is just to advise you that your application for contract will be processed as quickly as possible. Public Law requires that a routine inquiry may be made during our initial or subsequent processing which will provide applicable information concerning character, general reputation, criminal records, personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of the inquiry, if one is made, will be provided. Date Your Signature OL9511-EV/WFG

3 R Occidental Life Insurance Company of North Carolina LICENSED-ONLY AGENT S AGREEMENT I. APPOINTMENT With the execution of this agreement, Occidental Life Insurance Company of North Carolina, Waco, Texas, ( the Company ), hereby appoints you as a Licensed-Only Agent and you are hereby authorized, provided you have a valid license, to solicit offers for policies of insurance written by the Company and to submit to the Company applications for Life Insurance and Annuities through World Financial Group Insurance Agency, Inc. ("WFGIA") to whom you are assigned and under whose jurisdiction you shall operate, subject to the terms and conditions of this Agreement and the rules and regulations of the Company now in effect and as may be adopted by the Company from time to time. II. AUTHORITY It is understood that you have no other contractual relationship with the Company and that you are not, and you shall refrain from holding yourself out as, an employee, partner, joint venturer or associate of the Company. You are an independent contractor and are free to exercise independent judgment as to the time, manner, and place in which you undertake your activities hereunder and Company shall have no right or authority to direct or control your use of energy, initiative or time. It is understood that you shall have no authority, express or implied, for or on behalf of the Company or WFGIA, to incur any expense, to accept any risk of any kind, to alter, modify, waive or change any of the terms, rates or conditions of any advertisements, receipts, policies or contracts of the Company, to extend the time for the payment of any premium, to bind the Company or WFGIA by any statement, promise or representation, to waive any of the Company s rights or any of its requirements, rules or regulations, or to set any extra premium for extra risks or privileges. In addition, you are not to enter into any lease or purchase agreement in the name of the Company or WFGIA or to open any bank account or similar account where the Company name is to appear in the name of the account or on the withdrawal instrument or to borrow any money or to do anything of any kind or nature whatsoever except as may be authorized and directed by this Agreement. You may not advertise or publish any material or print or use any letterhead, circular or other matter including the name of or concerning the Company or its policies without advance written permission from the Company. It is understood and agreed that all premiums collected by you are trust funds to be held in accordance with applicable laws and that the same are the property of the Company and are to be paid over in full without deduction or discount. You shall pay to the Company the premiums on all policies immediately on receipt of same by you. You shall comply with the laws of the state(s) in which you are licensed and/or appointed and all regulations of such Department(s) of Insurance relating to your activities hereunder. III. COMPENSATION It is understood and agreed that the Company has no obligation to you for commissions, expense allowances or any form of compensation whatsoever in connection with the services performed and expenses incurred by you in the solicitation of applications for insurance issued by the Company, it being expressly understood that you are under direct contract with WFGIA, who has agreed to compensate you for such services. The Company has the right at all times and without liability to reject at its discretion, any application for insurance without specifying the reason therefore and to refund any premium on any policies or applications secured hereunder and to demand repayment of any commission or other benefit received on that premium by WFGIA. IV. TERMINATION Your appointment to represent the Company and this Agreement may be terminated by the Company, upon request of WFGIA, or upon its own initiative, at any time. Form OL3357-EV/WFG(4/14)

4 Upon termination you shall immediately pay all sums due the Company and shall deliver to the Company or its representatives all rate books, letters, records and supplies connected with the business of the Company belonging to the Company. Failure to return these supplies may result in a charge against you for the cost of the Company for these supplies. V. INDEMNIFICATION AND ASSIGNMENT You agree that you shall indemnify and hold the Company, its officers, directors, employees, agents, subsidiaries and affiliates, harmless from any and all loss, liabilities, damages, penalties or costs incurred by the Company when the Company is made party to any regulatory action, lawsuit or threat of either because of any act or omission by you, your employees, or agents, or resulting from or growing out of unauthorized, negligent, fraudulent or unfaithful acts or omissions by you, your employees or agents. Costs shall include, but are not limited to, attorneys fees, court costs, expenses, settlement costs, fines, judgments and all damage awards whether actual compensatory, punitive or otherwise. Nothing herein shall preclude the Company from seeking injunctive relief or any other remedy available at law for your breach of this Agreement. You are not permitted to assign this appointment or any interest in this appointment either before or after termination. VI. JURISDICTION This Agreement, wherever executed, is made and entered into in the State of Texas. Any disputes hereunder shall be determined in accordance with the laws of the State of Texas and jurisdiction and venue to hear and determine such disputes shall be vested irrevocably only in McLennan County, Waco, Texas. You hereby irrevocably submit to this jurisdiction. VII. RELEASE This Agreement constitutes the full and complete agreement between you and the Company and supercedes any agreement, contract, negotiation, discussion or understanding heretofore existing between you and the Company in writing or otherwise. This Agreement shall not be modified or amended except by agreement in writing, executed on behalf of the Company by a duly authorized officer. The failure of the Company to exercise any right or privilege hereunder shall not constitute a waiver of other rights or privileges nor shall such failure be deemed a waiver of any breach or future breach of any provision hereof. LICENSED-ONLY AGENT Print Full Name Signature OCCIDENTAL LIFE INSURANCE COMPANY OF NORTH CAROLINA BY: Date Date Form OL3357-EV/WFG(4/14)

5 CONSUMER REPORT NOTIFICATION AND AUTHORIZATION Through this document Occidental Life Ins. Co. of NC discloses to you that a consumer report or an investigative consumer report, is being obtained from a consumer reporting agency for the purpose of evaluating you for appointment as an agent. This report may contain information bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, criminal records, personal characteristics, or mode of living from public record sources or through personal interviews with your neighbors, friends or associates. You have a right to request additional disclosures regarding the nature and scope of the investigation and a written summary of your rights as a consumer. I authorize and request any consumer reporting agency to furnish any and all information in their possession regarding me in connection with my appointment for agent. A photocopy of this authorization may be accepted with the same request. I have the right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of this investigation. I authorize Occidental Life Ins. Co. of NC to share this information with the authorized representatives involved in my licensing and contracting process. Print Name Signature Form No. OL9127-EV/WFG

6 Compliance Guidelines Statement of Understanding I acknowledge that I have read and understand the contents of the Compliance Guidelines for Occidental Life Insurance Company of North Carolina referred to as the Company. I acknowledge that I have read and understand the contents of the Compliance Guidelines and further understand that if I do not comply, in full, with its provisions it will be a violation of my contract and may result in, without limitation, the cancellation of my contract with the before mentioned Company. 1. I acknowledge the need for strict compliance with all applicable state and federal regulations regarding the solicitation and sale of insurance. 2. I understand the Company will insist upon strict adherence to all applicable state and federal regulations regarding the solicitation and sale of insurance and understand that I am individually accountable for my own actions. 3. I acknowledge that I must be professional in my sales presentations. I acknowledge that I must accurately and completely describe the insurance product being offered, help the purchaser understand the terms and conditions of the insurance product being sold, and comply with all applicable state and federal regulations. I understand that violations of the Compliance Guidelines or applicable insurance regulations may result in the immediate termination of my contract with the company. 4. I understand that I must immediately take the Company approved anti-money laundering training course. I understand that I must take a refresher of the company online anti-money laundering training course every two years. 5. I acknowledge that this Agreement does not alter or amend my contract or contracts with the Company or create an employment relationship with the Company. This Agreement does not change the at-will relationship between the parties and me. The contract or contracts between the Company may be terminated at any time by either party upon notice, as set forth in those contracts. Producer Signature Producer (Print name) OL9528-C-EV/WFG 1