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 3250 Grey Hawk Ct. Carlsbad, CA 92010 Phone: 866-716-7242 Fax: 866-467-6701 Attention Marketing E-mail: info@sisinsure.com Page 1
PRODUCER QUESTIONNAIRE PAGE 1 OF 2 Legal Agency Name: DBA: Mailing Address: City: State: Zip: Street Address: Phone Number: ( ) --- Fax Number: ( ) --- Agency Type: Retail Wholesale Both 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 Email Page 2
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: Page 3
LIMITED PRODUCER AGREEMENT This agreement, is made and entered into between SafeBuilt Insurance Services, Inc. (SIS), dba: Structural Insurance Services (SIS) (hereinafter SIS ), and Producer: Mailing Address: Hereinafter Producer 1. Producer shall have no authority to bind any coverages on new or renewal business or claim hereunder, or make any changes in terms and conditions of any policy of insurance. 2. Producer shall have no authority to issue a binder in the name of SIS or any company represented by SIS. 3. In the event an unauthorized binder issued by the Producer through SIS or any company represented by SIS, suffers loss, Producer agrees to indemnify, hold harmless and defend SIS and/or any company represented by SIS, against any judgment or settlement and for all loss and expense, including, but not limited to, attorney fees and investigation costs, incurred by SIS or any company represented by SIS in the payment or defense or claim or loss resulting from said unauthorized binder. 4. SIS will allow Producer commissions at such rates as agreed to between the parties hereto. In the event of any return premium becoming due for any reason whatsoever, Producer shall refund any associated commission to SIS at the same rate at which the 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. Producer will pay to SIS, any and all open accounts, accounts stated or other indebtedness arising out of or relating to policies of insurance under this agreement. Producer 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 SIS. Producer shall be responsible for arranging for the return to the insured any unearned premium and unearned commissions that belong to the insured. Producer shall remit all payments to SIS within (10) ten days of Producer s receipt of such payment. Producer shall hold all payments received from insured in trust until payments are transmitted to SIS. No payment accepted or received by Producer shall be deemed paid to SIS until such payment shall be received in hand SIS. Any violation of the foregoing shall be considered a breach of the Producer s fiduciary responsibilities and obligations to SIS and its insurance companies and MGA(s). Producer recognizes that any violation of the terms of this paragraph shall be sufficient cause for rescission of this agreement. Page 4
6. The Producer may submit business from any State that the producer holds a current/active Property and Casualty Insurance License in. It is agreed that within those actively licensed states, the Producer shall be free to exercise his/her judgment as to the person(s) solicited and the time, manner, means and place of solicitations, and 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 SIS or any company represented by SIS. No act of the Producer shall be binding on SIS or any company represented by SIS. The Producer shall be transacting business on behalf of his/her client and not SIS. 8. SIS will take reasonable steps to give the Producer reasonable advance notice of the expiration of all policies, but failure to provide such notice shall not render SIS liable in this regard. So long as the Producer remains current, accounting for and paying all accounts for which he/she is liable, the Producer s records and use and control of expiration(s) shall be deemed the property of the Producer and remain in his/her sole, possession, and control. In the event that the Producer defaults on any accounts for which he/she may be liable, SIS has the right to cancel, revoke, or rescind this agreement and immediately retain control of any and all accounts in default, which are in the Producer s possession and control. 9. Producer agrees to indemnify and hold harmless SIS, any of its employees, agents, 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 by the Producer which results in any claim, loss, award, penalty, demand, action or cause of action against SIS or its underwriting companies, claim adjusting companies, or insurance companies, whether or not said claim, loss, award, penalty, demand, action or cause of action be meritorious. Producer agrees to promptly notify SIS of any claim, demand, action or cause of action made against Producer. Producer agrees to indemnify SIS and/or any of its underwriting companies, claim adjusting companies or insurance companies from any and all loss, expense, settlement or judgment including expenses of investigators, expert witnesses, court costs, and attorney fees arising from or relating to any alleged failure to act on the part of the Producer whether or not said claim, loss, award, penalty, demand, action or cause of action be meritorious. 10. Producer agrees to indemnify and hold harmless SIS, its shareholders, directors and employees, against any and all claims, demands, actions, liability, losses, damages, penalties, judgments, costs and expenses, including without limitation, attorney fees, disbursements and court costs, made or instituted against, or incurred by 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. SIS agrees to indemnify and hold harmless Producer, any of its employees, agents, or representatives, from and against any and all claims arising out of or relating to any alleged act or alleged failure to act by SIS which results in any claim, loss, award, penalty, demand, action or cause of action against Producer or any of its employees, agents, or representatives, whether or not said claim, loss, award, penalty, demand, action or cause of action be meritorious. SIS agrees to promptly notify Producer of any claim, demand, action or cause of Page 5
action made against SIS. SIS agrees to indemnify Producer, any of its employees, agents, or representatives from any and all loss, expense, settlement or judgment including expenses of investigators, expert witnesses, court costs, and attorney fees arising from or relating to any alleged failure to act on the part of the SIS whether or not said claim, loss, award, penalty, demand, action or cause of action be meritorious. 12. Producer agrees to indemnify and hold harmless SIS, any of its employees, agents, 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 by the Producer, in reliance on the Producer s capacity as power of attorney for any third party, which results in any claim, loss, award, penalty, demand, action or cause of action against SIS or its underwriting companies, claim adjusting companies, or insurance companies, whether or not said claim, loss, award, penalty, demand, action or cause of action be meritorious. 13. SIS agrees to indemnify and hold harmless Producer, its employees, agents, or representatives against and in respect of any and all claims, demands, actions, liability, losses, damages, penalties, judgments, costs and expenses, including without limitation, attorney fees, disbursements and court costs, made or instituted against, or incurred by Producer, its employees, agents, or representatives, which arise directly or indirectly out of any act or omission of SIS, or its employees or representatives. 14. Producer in placing business under this agreement recognizes that Producer is a representative of the insured and is not acting as an agent or representative of SIS or its insurance companies, or claim adjusting companies. 15. Neither SIS nor the insurance company shall bear responsibility for any expense incurred by Producer, regardless of the origin of the expense incurred. 16. Producer shall abide by the California Fair Claims Settlement Practices Regulations when handling claims. 17. 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 attorney fees, legal fees and costs, and other expenses arising out of such action. 18. Producer agrees that Producer 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, amendments, and exclusions contained within the policy of insurance. 19. Producer shall not reproduce and/or distribute any sample insurance policies to any party, other than a prospective insured in the normal course of business. Producer shall not post or cause to be posted, any sample policy or current policy of an insured on the internet or an internet website at any time. 20. 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 will send Page 6
a copy of the policies to SIS. 21. In the event any provision of this agreement shall be held illegal or invalid for any reason, the illegality or invalidity shall not affect the remaining parts of the agreement, and the agreement shall be construed and enforced as if the illegal or invalid provision(s) had not been included. 22. This agreement supersedes and replaces any and all previous agreements and shall be effective as of the date entered below and shall remain in full force and effect until cancellation. Cancellation may be effectuated by either party providing written notice of cancellation by mail to the party s last known address. Cancellation of this agreement will become effective after the date of mailing and any such cancellation shall comply with the laws of the State of California. 23. Failure to abide by all the terms and conditions of this agreement will result in the immediate suspension or termination of this Producer Agreement, at the sole discretion of SIS. In witness whereof, the parties hereby enter into this agreement on this day of 2012. SAFEBUILT INSURANCE SERVICES, INC. DBA Structural Insurance Services 3250 Grey Hawk Ct. Carlsbad, CA 92010 SIGNATURE: PRINT NAME: TITLE: PRODUCER: IRS # SIGNATURE: PRINT NAME: TITLE: Page 7
Print or type See Specific Instructions on page 2. 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. 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.) Exempt payee Requester s name and address (optional) City, state, and ZIP code List account number(s) here (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 301.7701-7). 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. 10231X Form W-9 (Rev. 10-2007)