12/3/09

AGENT INFORMATION FORM

Agent’s Name: Hierarchy: Mktr:

Listing of all Products:

Medicare Supplement: 0 1 2 3 4 5

Advancing: 6 9 12

Please indicate which state that this agent would like to be appointed in:

AL AR AK AZ CA CO CT DC DE FL GA IA ID IL IN KS KY LA MD ME MI MN

MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA SC SD TN TX UT

VA VT WA WI WV WY Add. States

Signed By: Date:

Please indicate any special instructions for this agent:

NOTES:

Contract Checklist for General Agent (Corporations)

Name: ______________________________________________________________________

REQUIRED DOCUMENTS FOR CONTRACTING

General Agent Agreemento Signature Page Signed & Datedo Full Name Printed or Typedo Tax Identification Number Section Completedo Certification Section Completed, Signed & Datedo Return Signature Page Only

Special Agent Agreemento Signature Page Signed & Datedo Full Name Printed or Typedo Tax Identification Number Section Completedo Certification Section Completed, Signed & Dated by the Principalo Return Signature Page Only

Background & Information Sheeto Personal Section Completedo Business Section Completedo Background Experience Questions 1 and 2 Answeredo Answering “YES” to either question requires a written, signed and dated explanation.o Signed & Dated

Fair Credit Reporting Act Disclosureo Signed & Dated

Check Deposit Authorization (Optional)o Completed, Signed & Datedo Voided Check or Deposit Slip Attached

Current State LicensesALL States in Which General Agent Will Be Soliciting Business.NOTE: For contracted entities who will not sell, solicit, negotiate or hold themselves out as an insurance agency, nolicense is required except in the following states:

Corporations: GA MS MO PA KY MT UT

Individuals: GA KS MS MO PA KY MT NC UT

ALL MATERIALS MUST BE RETURNED TO YOUR MASTER

GENERAL AGENCY TO CONTINUE THE CONTRACTING PROCESS

GRBChecklist 08-2009

PLEASE NOTE

Administrative OfficeP.O. Box 2271Omaha, NE 68103-2271

Call 1-800-863-8963Fax 1-402-997-1832

General Agent Agreement

BMO02G.001

This General Agent Agreement (“Agreement”) is between the undersigned General Agent (“GA”) andGerber Life Insurance Company (“Company”).

See Section K for definitions.

The parties agree as follows:A. Appointment Company authorizes

GA to solicit Product applications and torecruit Other General Agents. Companyagrees to appoint GA with the appropriatestate insurance departments for GA tosolicit Product applications. Thisappointment is not exclusive.

B. Compensation

1. For Each Product. GA’scompensation depends on theparticular Products sold.Compensation for each Productwill be as specified in theCompensation/ProductSchedules.Compensation/Product Schedulesmay be changed by Company atany time and will be distributed toGA.

2. Contingencies. In addition toany conditions imposed in theCompensation/Product Schedulesand any amendments, nocompensation is earned until:

(a) GA is licensed andappointed in accordancewith laws and Companyprocedures,

(b) the Product is actuallyissued, delivered to andaccepted by the customer,

and

(c) the premium for theProduct is paid to theCompany.

3. Compensation AfterTermination. GA shall not be

entitled to any compensation afterthe Termination Date of thisAgreement, except for:

(a) Vested Compensation,

and

(b) any net credit balance inGA’s account forcompensation earned as ofthe Termination Date.

4. Forfeiture. GA will forfeit allrights to receive compensation,including Vested Compensation,if, in the sole reasonable discretionof Company, GA commits any ofthe following acts:

(a) breaches any materialprovision of thisAgreement while in effector any material obligationthat survives terminationof this Agreement.

(b) commits a fraudulent orillegal act in connectionwith any activitiescontemplated under thisAgreement.

(c) does any act which resultsin the suspension orrevocation of GA’sinsurance license.

C. GA’s Duties

1. Licenses and Approvals. GAshall obtain and maintain andprovide copies of all necessarylicenses and regulatory approvals

BMO02G.001

to perform the services under thisAgreement.

2. Monitor and Communicate.GA may recruit Other GeneralAgents. GA shall monitor itsOther General Agents andcommunicate information toCompany, of which it is aware orshould be aware, that Companyneeds to know about its OtherGeneral Agents to properlyaddress compliance or other risks.When directed by Company, GAshall communicate Companyinformation to its Other GeneralAgents.

3. Solicitation. GA shall help itsOther General Agents in solicitingProducts. If GA is contracting asan individual, then GA may solicitapplications for Products.

4. Service. GA shall help its OtherGeneral Agents in servicingcustomers. If GA is contractingas an individual, GA shall provideservice to GA’s customers.

5. Confidentiality and Privacy.GA shall comply with the“Confidentiality and PrivacyAmendment” which is attachedhereto and incorporated into thisAgreement. Company mayunilaterally revise theConfidentiality and PrivacyAmendment upon written noticeto GA.

6. Compliance with Laws andConduct. GA shall comply withall applicable laws and regulationsand act in an ethical, professionalmanner in connection with thisAgreement, including, withoutlimitation, with respect to anycompensation disclosureobligations and any other

obligations it may have governingits relationships with its clients.

7. Compliance with CompanyPolicies. GA shall comply, andshall ensure its employees comply,and shall instruct and encourageits Other General Agents tocomply with all policies, practices,procedures, processes and rules ofCompany. GA shall promptlynotify Company if GA or any ofits employees or Other GeneralAgents are not in compliance withany Company policy, procedure,process or rule.

8. Insurance. GA shall have andmaintain Errors and Omissionsliability insurance covering GAand GA’s employees during theterm of this Agreement in anamount and nature, and with suchcarrier(s) satisfactory to Companyand provide evidence of suchinsurance to Company uponrequest.

9. Fiduciary Responsibilities. GAshall be responsible for all moneycollected by GA, GA’s employeesand its Other General Agents onbehalf of Company and shall remitto Company all payments andcollections received for or payableto Company from Other GeneralAgents, applicants, customers, orothers no later than 15 days afterreceipt, or within any shorterperiod required by law. All moneytendered as payment shall alwaysbe the property of Company andshall be held by GA purely in afiduciary capacity and not forGA’s own benefit. GA is notauthorized to spend, cash ordeposit for any purpose anyportion of such money.

10. Records. Except as provided inthe Confidentiality and Privacy

BMO02G.001

Amendment, GA shall keepregular and accurate records of alltransactions related to thisAgreement for a period of at leastfive years from the date of suchtransactions, or longer if requiredby federal or state law orregulation.

11. Advertising Materials. GA shallobtain Company’s writtenapproval prior to using anyadvertising material or scriptidentifying Company or Products,except such material provided byCompany and used pursuant toCompany’s instructions.

12. Notice of Litigation orRegulatory Proceeding. GAshall promptly notify Companyupon receiving notice of potential,threatened, or actual litigation orany regulatory inquiry orcomplaint with respect to thisAgreement or any Product.Company shall have finaldecision-making authority toassume the administration anddefense of any such action. Acopy of the correspondence ordocument received shallaccompany each notice.

13. Delivery of Documents toCustomers. Upon request fromCompany, GA shall deliver to itscustomers any information thatCompany provides to GA for thepurpose of fulfilling Company’sobligation to provide suchinformation to the customer,including without limitation,Schedule A to Form 5500 and anyother information relating tocompensation paid to GA byCompany. GA shall deliver suchinformation to its customerswithin the time period required byERISA or other applicable law or

as otherwise instructed byCompany.

D. Limitations GA, either directly orthrough its employees or Other GeneralAgents, shall not:

1. Expense or Liability. Incur anyexpense or liability on account of,or otherwise bind Companywithout specific prior writtenapproval from an AuthorizedRepresentative.

2. Alteration. Alter any advertisingmaterials or make, alter, waive ordischarge any contracts orProducts on behalf of Company.

3. Premium Payments andReinstatement. Extend the timefor payment of any premium orwaive any premium, or bindCompany to reinstate anyterminated contract, or acceptpayment in any form other than acustomer check or money orderpayable to the Company or othermethod authorized by Company.

4. Respond in Connection withProceeding. Institute or file aresponse to any legal or regulatoryproceeding on behalf of Companyin connection with any matterpertaining to this Agreement orany Product, without Company’sprior written consent.

5. Replacement. Replace anyexisting insurance product orannuity contract unless thereplacement is in compliance withall applicable laws and regulationsand is in the best interest of thecustomer. The decision whetherto replace an insurance product orannuity contract should be madeby the customer. To help thecustomer make a decisionregarding any proposed

BMO02G.001

replacement, GA must provide thecustomer with full disclosure(both positive and negative) of allrelevant information.

6. Misrepresentation. Misrepresentor induce any Other GeneralAgent to misrepresent, anyprovision, benefit, or premium ofany Product.

E. Compensation Administration

1. Accounting. Company willaccount to GA for payablecommissions based upon initialand renewal premiums receivedand accepted by Company forpolicies issued upon applicationssubmitted by or through GA.Company reserves the right tofreeze GA’s account for areasonable period of time toensure that funds are available toreimburse the Company for anyIndebtedness.

2. Effect of Return of Premium.Except where provided on aCompensation/Product Schedule,if any premiums shall be returnedby Company on any policy orcontract, or should Companybecome liable for the returnthereof for any cause either beforeor after the Termination Date, GAshall pay to Company allcompensation previously paid orcredited to GA’s account on suchreturned premium.

3. Set-Off. Company is authorizedto set-off and apply any and allamounts due to GA fromCompany under this Agreement toany and all obligations orIndebtedness of GA or itsemployees, Other General Agentsor affiliates to Company or itsaffiliates. This right of set-offdoes not require Company to

make any prior demand upon GA,and the right exists irrespective ofwhether the obligations of GA orits affiliates are contingent orunmatured. The rights of theCompany under this Section E.3are in addition to any other rightsand remedies which the Companymay have under this Agreement orotherwise.

4. Interest. Interest will accrue onany amount due under thisAgreement, which has not beenpaid within 30 days of receipt ofwritten demand for such amountat the rate of one percent permonth, or the highest ratepermitted by law, whichever islower.

5. Limitation of CompensationActions. Any claim by GAregarding compensation must bebrought within one year from thedate the compensation wasreported on an accounting issuedfrom Company to GA. Any claimregarding compensation must bebrought against the corporationwhich issued theCompensation/Product Scheduleto which the claim relates.

F. Termination With or WithoutCause In addition to the terminationprovisions set forth in the Confidentialityand Privacy Amendment, GA orCompany shall have the right at any timeto terminate this Agreement, with orwithout cause, upon written notice to theother party. Termination shall beeffective as of the Termination Date.

G. Independent Contractor GA is anindependent contractor and not anemployee of Company. Subject to legaland regulatory requirements, GA shall befree to exercise GA’s own judgment as tothe persons from whom GA will solicit

BMO02G.001

and the time and place of suchsolicitation.

H. Inspection of Books and RecordsCompany shall have the right, duringnormal business hours and withreasonable notice, to inspect, audit andmake copies from the books and recordsof the GA for the purpose of verifyingGA’s compliance with the provisions ofthis Agreement.

I. Indemnity and Hold HarmlessEach party shall indemnify and hold theother party harmless from any liability,loss, costs, expenses (including reasonableattorneys’ fees incurred by theindemnified party) or damages, includingpunitive and extra-contractual damages,resulting from any act or omission of itsobligations provided in this Agreement bythe indemnifying party or any of itsemployees or Other General Agents in theperformance of its duties under thisAgreement or other agreements withCompany, including without limitation,any breach of its obligations providedunder this Agreement.

J. General

1. Issue and Product Type.Company shall retain the right todecide whether to issue orwithdraw a Product and determinethe type of Product to be issued orwithdrawn. Company maydiscontinue or change a Product atany time.

2. Producer of Record. Theproducer of record for anyProduct shall be determined byCompany records. Companyreserves the right to change theproducer of record according toCompany procedures and shallhave no obligation to designate asuccessor producer of record.

3. Notice. Any notice required orpermitted to be sent to Companyunder this Agreement shall bedelivered personally or sent byU.S. Mail with all postage prepaidor by express mail to:

Gerber Life Insurance CompanyPO Box 2271Omaha, Nebraska 68103-2271

4. Entire Agreement. ThisAgreement, the Confidentialityand Privacy Amendment and theCompensation/Product Schedulesconstitute the entire agreementbetween the parties regarding theProducts sold under thisAgreement.

5. Governing Law. This Agreementshall be governed by the laws ofthe State of New York, withoutgiving effect to that State’sprinciples of conflicts of law.

6. Severability. In the event anyprovision of this Agreement isfound to be invalid orunenforceable, the remainingprovisions shall remain in effect.

7. No Waiver. Failure of Companyto enforce any provision of thisAgreement shall not operate towaive or modify such provision orrender such provisionunenforceable.

8. No Assignment or Change.Except forCompensation/ProductSchedules, Confidentiality andPrivacy Amendments and otheramendments to the Agreementwhich are required by federal, stateor local laws or regulations, nomodification, amendment orassignment of this Agreementshall be valid unless approved inwriting by an Authorized

BMO02G.001

Representative.Compensation/ProductSchedules, Confidentiality andPrivacy Amendments and otheramendments to the Agreementwhich are required by federal, stateor local laws or regulations may bedistributed only by Company butneed not be signed by either partyto be effective.

9. Survival. GA’s appointmentpursuant to Section A of thisAgreement shall immediatelyterminate on the TerminationDate. Except for Sections C.2 andC.3 of this Agreement, all otherprovisions of this Agreement shallsurvive its termination.

10. Beneficiary. If GA is anindividual, then GA designates thebeneficiary specified on thesignature page or such other partyor parties as GA may designate bywritten notice delivered to andrecorded by Company, asbeneficiary for payment of anycompensation becoming due afterGA’s death.

11. Headings. Any section or otherheading contained in thisAgreement are for referencepurposes and convenience onlyand shall not affect, in any way,the meaning and interpretation ofthis Agreement.

12. Counterparts. This Agreementmay be executed in counterparts,each of which shall be deemed anoriginal, but all of which togethershall constitute one and the sameinstrument.

K. Definitions The following terms havethe following meanings. Any singularword shall include any plural of the sameword.

1. “Authorized Representative”means the Chief Executive Officeror President of a Company or anindividual authorized in writing bythe Chief Executive Officer orPresident.

2. “Compensation/ProductSchedule” means a Company’sdistributed commission schedulethat (a) specifies the amounts andconditions under whichcommissions will be due andpayable to GA for any Product,and (b) is made a part of thisAgreement.

3. “Indebtedness” means anyamounts owed by GA toCompany, including but notlimited to (a) the chargeback ofany compensation paid or creditedto GA under this or any otherAgreement, if the monies onwhich such compensation wasbased are not collected or arerefunded by the Company, (b) anyadvances made by Company toGA, (c) any expenses incurred bythe Company on behalf of GA,and (d) any amount paid by theCompany, which in itsdetermination resulted from fraud,misrepresentation or otherimproper conduct by the GA.

4. “Other General Agent” meansany individual or organization,which (a) enters into a generalagent, representative or othermarketing agreement withCompany and (b) submits Productapplications that designate GA.

5. “Product” means any insurancepolicy, contract, investmentvehicle or other offering identifiedin any Compensation/ProductSchedule.

BMO02G.001

6. “Termination Date” means thelater to occur of (a) the date onwhich GA or Company sendswritten notice of termination tothe other party, or (b) the datespecified by GA or Company in awritten notice of termination tothe other party.

7. “Vested Compensation” meanscompensation identified as vested

on a Compensation/ProductSchedule and that may be paid toGA after the Termination Date if(a) the policy related to theProduct remains in force, (b) thepremiums for the policy are paidto Company, and (c) if GA is thewriting agent, GA remains theproducer of record.

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BMO02G.001

General Agent

_______________________________________________Sign Name (required)

_________________________________________________Print Name

_________________________________________________Title

_________________________________________________General Agent

_________________________________________________Date

_________________________________________________ Designated Beneficiary

Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. For individuals, this is your social security number. For otherentities, it is your employer identification number.Social Security Number Employer Identification NumberOR

CertificationUnder penalties of perjury, I certify that:

1. The number provided is my correct taxpayer identification number, and2. 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 backupwithholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified methat I am no longer subject to backup withholding, and

3. I am a U.S. person (a U.S. citizen or U.S. resident alien or a partnership, corporation, company orassociation created or organized in the U.S. or under the laws of the U.S. or an estate (other than aforeign estate) or a domestic trust (as defined in Regulations section 301.7701-7)).

Certification instructions: You must cross out item 2 above if you have been notified by the IRS that youare currently subject to backup withholding because you have failed to report all interest and dividends onyour tax return.The Internal Revenue Service does not require your consent to any provision of this document otherthan the above-referenced certifications required to avoid backup withholding.

SignHere

Signature ofU.S. person

Date

[Remainder of page blank]

BMO02G.001

Gerber Life Insurance Company

Please do not complete this page. If approved, you will receive an executed copy of this contract page.

General Agent Agreement

_________________________________________________By

_________________________________________________Name

_________________________________________________Title

_________________________________________________Date

A-1

Confidentiality and Privacy AmendmentGeneral Agent

This “Confidentiality and Privacy Amendment” is made a part of and incorporated into the General AgentAgreement between GA and Company (“Agreement”) and is effective on the effective date of theAgreement. To the extent any provision of the Agreement conflicts with or is inconsistent with anyprovision of this Confidentiality and Privacy Amendment the provisions of this Confidentiality and PrivacyAmendment shall control. All other terms and conditions of the Agreement not inconsistent with the termsof this Confidentiality and Privacy Amendment shall remain in full force and effect.

A. Definitions

Except as otherwise defined, any and allcapitalized terms in this Amendment shall havethe definitions set forth in the Privacy andSecurity Rules.

1. “Confidential BusinessInformation” means thefollowing nonpublic business orfinancial information whether inwritten, oral or electronic form:information which relates tocustomers or the business ofCompany including withoutlimitation, sales and rateinformation, software, businessplans and operating strategies,Product information, personalinformation that is not consideredProtected Health Information, andmaterial identifying an associationwith the Company. ConfidentialBusiness Information does notinclude (a) information similar toConfidential Business Informationwhich is independently owned anddeveloped by GA or (b)information relating to direct orindirect compensation payable,paid or provided to GA under theAgreement.

2. “Confidential Information”means Confidential BusinessInformation and Protected HealthInformation.

3. “Privacy and Security Rules”shall mean the Standards forPrivacy of Individually IdentifiableHealth Information and theSecurity Standards for theProtection of Electronic ProtectedHealth Information at 45 CFRpart 160 and part 164, as they maybe amended from time to time.

4. “Protected HealthInformation” shall have the samemeaning as that assigned in thePrivacy and Security Rules limitedto the information created orreceived from or on behalf ofCompany.

5. “Representative” means allofficers, directors, employees,agents, consultants,representatives, subcontractors,professional advisors and affiliatesof GA.

B. GA’s Obligations RegardingConfidential Information

1. Non-Disclosure of ConfidentialInformation. GA agrees to retainall Confidential Information instrict confidence. GA will not useor disclose ConfidentialInformation to others except toGA’s Representatives forpurposes related to GA’sperformance of its obligationsunder the Agreement, providedthe Representative is first

A-2

informed of the confidentialnature of such information andthe obligations set forth herein,and agrees to be bound therebyand provided such disclosure isnot otherwise prohibited underthe Agreement. GA is responsibleto Company for a breach ofconfidentiality by itsRepresentatives.

2. Safeguarding. GA agrees to useappropriate safeguards commonlyavailable, such as anti-virus,firewalls and encryption, toprevent use or disclosure ofConfidential Information otherthan as provided for by theAgreement. This shall include,without limitation, compliancewith all existing and enacted lawsand regulations.

3. Reporting Unauthorized Use orDisclosure. GA agrees to reportto Company any incidentsinvolving use or disclosure ofConfidential Information notprovided for by the Agreement.Such report shall be made as soonas possible, but in no event laterthan three business days followingthe date that GA becomes awareof such unauthorized use ordisclosure. All details of theincident shall be provided so thatCompany can assess the scope andimpact and take additional actionas necessary to safeguard theinformation. GA shall takeaction(s) requested by Company, ifany, to mitigate such unauthorizeduse or disclosure.

4. Information RegardingConfidential Information. GAagrees to adequately inform itsRepresentatives of the obligationsset forth herein relating toConfidential Information.

5. Offshore Outsourcing. GAagrees that it will not allow anyConfidential Information to leavethe United States without priorwritten consent of the Company’sPrivacy Office. GA further agreesto ensure that any Representativeto whom it provides customerinformation agrees to the samerestriction.

C. GA’s Obligations RegardingProtected Health Information

1. Non-disclosure of ProtectedHealth Information. GA agreesto not use or further discloseProtected Health Informationother than as permitted orrequired by the Agreement or asRequired by Law without priorwritten authorization byCompany’s Privacy Office.

2. Safeguarding. GA agrees to useappropriate safeguards to preventuse or disclosure of ProtectedHealth Information other than asprovided for by the Agreement.Additionally, GA agrees toimplement administrative,physical, and technical safeguardsthat reasonably and appropriatelyprotect the confidentiality,integrity, and availability of theelectronic Protected HealthInformation that it creates,receives, maintains, or transmitson behalf of Company.

3. Reporting Security Incidentsand Unauthorized Use orDisclosure. GA agrees to reportto Company’s Privacy Office anysuccessful security incident ofwhich it becomes aware and anyuse or disclosure of the ProtectedHealth Information not providedfor by the Agreement. Suchreport shall be made as soon as

A-3

possible, but in no event later thanthree business days following thedate that GA becomes aware ofsuch successful security incidentor unauthorized use or disclosure.GA shall take action(s) requestedby Company to mitigate any suchunauthorized use or disclosure.GA will report any securityincident that is attempted but notsuccessful of which it becomesaware only upon receipt of awritten request from Company.

4. Representatives. GA agrees toensure that any Representativewho creates or receives from oron behalf of GA any ProtectedHealth Information agrees to thesame restrictions and conditionsset forth in the Agreement,including the implementation ofreasonable and appropriatesafeguards to protect electronicProtected Health Information.

5. Access to Protected HealthInformation. At the request ofand in the time and mannerdesignated by Company, GAagrees to provide access toProtected Health Information toCompany, or as directed byCompany, to an Individual inorder to meet the requirementsunder 45 CFR 164.524.

6. Amendment of ProtectedHealth Information. GA agreesto make any amendment(s) toProtected Health Information thatCompany directs or agrees topursuant to 45 CFR 164.526 in thetime and manner designated byCompany.

7. Accounting for Disclosures.GA agrees to document andimmediately notify Company’sPrivacy Office of its disclosure ofany Protected Health Information

for purposes outside ofTreatment, Payment or HealthCare Operations, as each term isdefined in the Privacy and SecurityRules. With regard to each suchdisclosure, GA will provideCompany’s Privacy Office (a) thedate of the disclosure, (b) thename of the entity or person whoreceived the Protected HealthInformation, and, if known, theaddress of such entity or person,(c) a brief description of allProtected Health Informationdisclosed, and (d) a brief statementregarding the purpose andexplanation of the basis of suchdisclosure and the name(s) of allIndividuals whose ProtectedHealth Information was disclosedin accordance with 45 CFR164.528.

8. Inspection of InternalPractices, Books and Records.GA agrees to make its internalpractices, books, and records,including policies, procedures andProtected Health Information,relating to the use and disclosureof Protected Health Informationavailable to Company, or at therequest of Company to theSecretary or their designee, in atime and manner designated byCompany or the Secretary forpurposes of determiningCompany’s compliance with thePrivacy and Security Rules.

D. Return or Destruction ofConfidential BusinessInformation and ProtectedHealth Information Upontermination of the Agreement, for anyreason, GA will promptly return ordestroy all Confidential BusinessInformation. Upon written request ofCompany, the destruction or return ofsuch information shall be confirmed in

A-4

writing. Upon termination of theAgreement, for any reason, GA shallreturn, if feasible, all Protected HealthInformation that GA maintains in anyform and retain no copies of it. If thereturn of any Protected HealthInformation is not feasible, theprotections of the Agreement shall beextended to the Protected HealthInformation and GA’s use and disclosureof such Protected Health Informationshall be limited to those purposes thatmake the return of the Protected HealthInformation not feasible, for so long asGA maintains the Protected HealthInformation.

E. Disclosures Required by Law ora Governmental Authority If GA isrequired to disclose ConfidentialInformation in response to legal processor a governmental authority, GA shallimmediately notify Company’s PrivacyOffice and, upon request, cooperate withCompany in connection with obtaining aprotective order. GA shall furnish onlythat portion of the ConfidentialInformation which it is legally required todisclose and shall use commerciallyreasonable efforts to ensure thatconfidential treatment will be accordedsuch Confidential Information.

F. Compliance with Laws GA shallcomply with its obligations under theAgreement and under any applicable state

or federal law or regulations as may be ineffect or as may hereafter be enacted,adopted or determined regarding theconfidentiality, use and disclosure ofConfidential Information.

G. Amendment This Confidentiality andPrivacy Amendment shall be amended toconform to any new or different legalrequirements that result from any changes,revisions or replacements of the Privacyand Security Rules, on or before theeffective date thereof. Company maychange, revise or replace thisConfidentiality and Privacy Amendmentin its sole discretion upon notice to GAwithout the consent of GA. In the eventof a conflict between the requirements ofthis Confidentiality and PrivacyAmendment and those of the Privacy andSecurity Rules, the Privacy and SecurityRules shall control.

H. Survival The respective rights andobligations of GA under thisConfidentiality and Privacy Amendmentshall survive the termination of theAgreement.

I. Termination for Violation of thisConfidentiality and PrivacyAmendment Company may terminatethe Agreement, effective immediatelyupon notice to GA, if GA has violated theterms of this Confidentiality and PrivacyAmendment.

Acknowledged by Company:

Name Thomas Conde ___Title Senior Vice President

By

GBRBGINFO 8-2009

BACKGROUND AND INFORMATION SHEET

Name:

Social Security Number: Date of Birth:

Home Address (must be a physical street address):

Home Phone: Cell Phone: (optional)

E-mail Address: (optional)

Business Name: (if applicable)

Personal Business Address: *Note – All correspondence (including compensation statements), will be mailed to the personal business addressindicated. Only one business address is supported per individual. If no business address is indicated, mail will bedirected to home address.

Address for overnight packages (cannot be a P.O. Box):

Business Phone: Business Fax:

Tax I.D. Number: E-mail Address:

Please identify your Master General Agency (if applicable):

Candidate Signature Date

BACKGROUND EXPERIENCE. Note: Please read each question carefully. Failure to answer “Yes”below, when appropriate, may result in the denial of your request to be contracted.

1. Have you ever been fined, suspended, placed on probation, paid administrative costs, entered into a consentorder, been issued a restricted license or otherwise been disciplined or reprimanded, or are you currentlyunder investigation by any insurance department, FINRA (formerly known as the NASD), SEC or any otherregulatory authority?__________Yes_________No

2. Have you ever been convicted or plead guilty or nolo contendere (no contest), served any probation, paidany fines or court costs, had charges dismissed through any type of first offender or deferred adjudication orsuspended sentence procedure, or are any charges currently pending against you for any offense other than aminor traffic violation?__________Yes_________No

PROVIDE A WRITTEN EXPLANATION AND APPLICABLE SUPPORTING DOCUMENTATION (i.e.,court documents, insurance department documents, etc.) FOR ANY QUESTION TO WHICH YOURESPONDED “YES”. Please be sure to date and sign the written statement.

GBRFCRA 8-2009

FAIR CREDIT REPORTING ACT DISCLOSURE

Gerber Life Insurance Company will obtain and use consumer reports for the purpose of serving as a factor inestablishing your eligibility for contracting as an insurance producer. We will obtain these consumer reports from:

First Advantage Corporation100 Carillon Parkway, Suite 100

St. Petersburg, FL 33716

“Consumer report” means a written, oral or other communication of any information by a consumer reporting agencybearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristicsor mode of living which will be used by Gerber Life Insurance Company, in whole or in part for the purpose of servingas a factor in establishing your eligibility to be contracted as an insurance producer.

This means a credit report, criminal report and report of insurance department regulatory actions will be obtained andreviewed as part of a background investigation in order to determine your eligibility to be contracted and appointed.

For California, Minnesota and Oklahoma: You have a right to request a copy of the consumer report which willdisclose the nature and scope of the report.

Yes, please provide me a copy of the consumer report

For New York: You have a right, upon written request, to be informed of whether or not a consumer report wasrequested. If a consumer report is requested, you will be provided with the name and address of the consumer reportingagency furnishing the report.

CANDIDATE’S STATEMENT – READ CAREFULLY

Gerber Life Insurance Company is hereby authorized to obtain and use a consumer report of my criminal record history,insurance department history and credit history through any consumer reporting agency or through inquiries with mypast or present employers, neighbors, friends or others with whom I am acquainted. I understand that this consumerreport will include information as to my general reputation, personal characteristics and mode of living.

AUTHORIZATION

I authorize any consumer reporting agency, insurance department, law enforcement agency, the Financial IndustryRegulatory Authority, The Securities and Exchange Commission or any other person or organization having anyconsumer report records, data or information concerning my credit history, public record information, insurance license,regulatory action history or criminal record history to furnish such consumer report records, data and information toGerber Life Insurance Company.

I understand that if contracted, this authorization will remain valid as long as I am contracted with Gerber LifeInsurance Company.

A photocopy of this authorization shall be considered as effective as the original.

Candidate Signature Date

Print Name

Check Deposit AuthorizationI, the undersigned, do hereby authorize Gerber Life Insurance Company to deposit my check as indicated below.This authority is to remain in full force and effect until Gerber Life Insurance Company has received notificationfrom me of its termination in such time and in such manner as to afford Gerber Life Insurance Company areasonable opportunity to act on it. In no event shall it be effective with respect to entries processed prior toreceipt of notice of termination.

I understand, this is not an assignment of commissions. 1099’s will continue to be issued to the commissionowner.

New Deposit or Change Deposit

Name of Bank

Bank Routing Number

Checking Account No.

or

Savings Account No.

This electronic deposit is for (check one): Company or Individual

Printed Name

Signature

Tax ID or Social Security Number

Producer Number

Effective Date

Telephone Number ( ) - _

A Voided Imprinted Check, Savings Deposit Slip or a Letter from the Bank Must Be Attached toVerify Account and Routing Numbers

Mail toGerber Life Insurance Company or Fax to 1-866-931-5503Attn: 6 – IDN CompensationP.O. Box 2271Omaha, NE 68103-2271

Gerber EFT

Administration Use Only

Entered & Verified By _________________________________________________Date __________