Trans America Contracting

8/14/2019 Trans America Contracting

1/14

I r--.rE TRANSAMERIC"q,G. IT.SUn.ANCE .IN1I8STMENT ROTJP

Kans$ City, MO 64141-6J21

E Trrntamcrica Oclidcotrl Lif. Irrdrrncc CompanyHomc Office Ccdar Raoids.lA 52499Admidstrerivc Office PiO. box 419521Kense! Gry, MO 64141-6J21

I Tran*ocrica Lifc lrrur.nc. CompenyHomc Offic.: Ccd.r R.pids, A 52499AdminisE iv Oflicc:PO. Box 4t9521

CONTRACT ATPLICAIION FOR:E Ag[t Cqrtraci (ftl-tin Carce( g.nt)E Iadepeadent Producer Contract Frokcr)El Sales Director {epp[c,riotrcqdred tr

individu.li mt or.raidy codrrect d drhTrintiddic.l

Requesting GA Name: Of6ce D: .-..-..'-................._ate: _ l_l

Applicant is: O An Individual O A Corporation O A Partnership

I am requesting an agreement with:

E Transamerica Occidcntal Lifc Insurancc Company (TOLIC - Fixcd Life)E Tlansamerica Life lnsurancc Company (TLIC)

I am also requesting the company(ics) makc application(s) to thc Deparunent(s) of Insurancc for the issuance of a license and/orappoinment -authorizing thc sol.icitation of applications on behalf of the company(ies). I understand that I may sot solicitapplications for tie compaoy

(Please ce Part VI for additional provisions rcgarding al4rlic.nt's agreemcnt o bc bouud by the Agent aodl or IPC conrract orcontracb).

Section A: (If applicart is an ind.ividual, cooplcre secior A only.)

Social Security Number:-------:----------:--. Do you plan to markct using a DBA? E Yes O No If so, please providethe supportitrg documentation, i.c., approval of required lurisdiction(s), DBA Name:(See pace six for sctrral insttuctions conccruine TaxDaver Idedtiftcetion Nunbet (TSee Page six for gcneral insttuctions conccruing Taxpayet Ideotification Nuober (TIN) IDforE tiotr.)

Home Phoae #: ( L-- Ccll Phone #: ( Pagcr #: (Business Phone #: ( ) Fax#: ( ) Email Ad&css:

trM!

EMrs.

!Mg D.O.B.-/- /_

BusinesVAlternate ddrcss: Drivcr's License

Last Name: First Name: Middle Name:

Statc:

city Zip Code

Ciry Zip Code

Stat Zip CodetrcctHow long at this residencc addrcss?

Residence Address: Street

CirY

-Ycare - Months

CitY

If less han five ycars, pleaee provide past five years below:

Stete Zio Code

Section B; {Ifapplicant s e corporatior or partncrship, complcte cctionB only).Parmership r Corporate Firm Name:

Do you plan to do business as a DBA? tr Yes n No Ifso,please rovidetre opponing oclffe'iAc*g,T.I,Tf,F3fft8l*t'required jurisdictiou(s), DBA Name: , and EIN for DBA if acquired -(See page six for gcneral instructions conccrning Taxpayer Identification Number (TIN) Idormation)

illlililtffiOA556-1105 Pagc of 8'DC1?r


2/14

Business hone #: ( )Business/Alteruate ddress: Street

Fax #: ( )- EmailAddress:City Zip Code

Mailing/Primary Ad dtes* (if different tom Bushess Addrcss)

Name of person who will sign as principal of this organizatiou Titlc

(Pleasc omplete Pan Il Section A for ptiocipal)(ASolicitorApplicetio! form TOA 560, nurt be complercd or edditioml priacipds aud eigdrg of6ccrs,)For corporatiodparmership, ivenames f all ofliccrs and priocipals, and heir titlcs, If aeccssarn lcasc otrtinuc n a seperate hect of papcr.(Plcasc omplae a SolicitorApplication orm for cach pcrson who will solicitTraaramcica business n bchalf of thc corpo..tion or p.rtncrsf,ip.

NAME TITLE TITLEAME

1) How long have you bccn an insurance agent or broke!?Below, please ist the compa es hat you currently reprcsent:

Company Name: Effective Date:

2) U this ioloruration covcrs ess han fir'e years, please provide details of employment history to completc the five-yeaf periodin the following section.

Employer Address Position

3) Are you row or have you ever bcen contracted with any Transamerica companyl Q Yes ONoIf yes, with which agency?

4) Please provide a copy of your individual ard/o! corpolate lcsidcnt Iiccnse and/or a copy of your Letter of Certificatiou, ifyolu resident statc requircs such).

5) Do you plan to solicit Transamcrica busincss n othcr iurisdiction? O Yes E No If so, arc you clrrendy licensed nthosc states? DYes E No If yes, plcase provide details i-ocluding copy(ics) of liccnse(s) or tho6e states.(Ple4se fouide copy(ies) of non-tesident kease(s) dnd.

etd non-resident ..s). lf. \ot,please be

alr'ale thatno solicitation of

business may occur until you arc properly liccused and appointed as rcquired in those states.

5) Do you plan to have any of your employccs solicit Traosaurcrica business on your behalf? O Yes D No. If so, pleasehave cvcry employee soliciting Transarncrica busincss complcte a Solicitor Application form.

TOA 556-'t105 Page ot 8


3/14

The following questions must be aaswered by the applicaoL ff the applicatt is a corporation or paruerqhip, tle questiousapply to the fiIm and to each of its priocipals and officers. I/ yot ansuet YES to ary questions, pbase @n plcte alctaik dnd4lat diaL on a wafltu sheet of pqer anil proaide seppotting doaonsntotion-

tt

J'

1) Have you ever bccn convicted of, pled guilry or no contest to a felony o! misdcmeanor?Note: you iray orrrit flisdemeanot oivictions for possexiox of metijuane hat occvrteil motethan two yea6 dgo.

5)

Is there any criminal indictment or criminal proceeding pending againet you?

Have you, or any business of which you were or plesently are a principal, been nvolved in abankruptcy action within the last seven years? (If YES,please ttach detailed explanation and a copyof the discharge apers, f applicable.)

Have you been a plaiatiff or defendant in any court proceeding within the last seven yearslNota Yor nay onit actiorLt ntobhg tnattet of family laut,

Do you presently have, or have you ever had, aoy professional designations or membe$hips inindustry organizationsl (If YES, please rovide a ist of such designations r ocmbetships and ndicstedates of activity.)

6) Have you ever had any license denied, suspcnded or revoked, or bccn the subject of a disciplinaryactiotr which resulted in a fine, penalry or restricted liccuse status? "LicenEe" shall include thefollowing: a liccnse issued by a state nsurance department, a state securities agency, he NASD,the SEC, or any other regulatory agency (or any other professional licettse or d,esignation),

7) Have you ever been discharged, or have you ever been equested o rcsign, from any enployment?

8) Have you ever had any company appoioturents involuntadly terrninated?

9) Are there any outstanding judgments, liens, or gamishments against you, or any business of which

you wele o! pfesently are a principal?

10) Do you have urresolved matters pelding with the Intemal Reyenue Service or other taxingauthorities ?

D Yes ENo

O Yes ENo

DYes QNo

Q Yes DNo

fl Yes O No

E Yes QNo

El Yes tr No

O Yes ENo

EYes QNo

flYes ENo

4l

11 Does any insureg general agcut, agcnt, or broker daim you are indebted to it for unpaid prerniums, E Yes E Nomishandling collateral, losses sustained, or any other rcason?

12) Has any EBcO carricr denied, paid claims on, or canceled your coverage?

13) Are you currendy covered under an EBcO policy? If ycs, give details on the next line.(Pleesc prot,ide copy of policy face page or ccfiificate.)

Namc of Carrier:

Coverage xp. Date -l_ l_ Amount of Coveragei_

1.4) {as a bonding or surety company denied, paid out on, or rcvokcd a bood for youl

15) llave you ever had a bond declined or canceled?

16) Are you currendy bonded?

E Yes 0No

E Yes ENo

Q Yes ENo

OYes ENo

OYes ENo

TOA 556-1 t05 Pag. 3 of 8


4/14

Notice to Persons Applying for Salcs Rcprestrtatiye Positionswith Transamerica Occidental Lifc Iqsuralce Compatry and Tiansamcrica Lifc Insurance Cornmpany

Federal law requires you be advised that in connection with your application to rcprestrt Transamqica Occidental LifeInsurancc Compaay and Transarncrica Life Inswaace Company (referred to as Transamerica" ) for the pu4rose of selling itsproducts, a consumer rcpon andlor investigative consurner repon may bc prepared whercby information is obtained throughcredit reponing agencies and./or pcrsonal interviews with your ncighbors, friends, or others with whom you are acquainted.Such reports are usually pan of the process of evaluating suitability for a sales epresentative position. Inquiry may bc madeinto your character, general rcputation, pcrsonal characteristics, and modc of living and credit information. It is possiblc thata representative f a firm employed o make such eports may call upon you rn person.

You have a right to rcquest disclosure of the nature and scope of the investigation upon wrirten request to our !{ome Officemade within a reasonable ime after the receipt of this notice. A summary of your rights undcr thc Fair Credit Reporting Actis attached hercto.

Authority for Relcasc of InformationTo Whom It May Concem:

I hereby authorize Traruamerica or its legal representative to obtain any information ftom former or curcnt cmployers,criminal justice agencies, onsumc rcporting agencies, or individuals, rclatiog to my activities. This information may hclude,but is not ligrited to achievement, performance, attendancg pcrsonal history c.edit and conviction records. I hereby dircctyou to release such nformation upon request o

Transamerica or its legal reprcscntativc. I undcrstand that Transamerica or itslcgal representativc may bc rcquircd by law to release nformation obtained to govemrnent agencies.

I hereby elease ll persons and entities, ncluding ecord custodians, rom any aod all liability for damages fwhatevcr kindor nature which may at any tirnc result to me on account of compliance, or any anempts to comply, with this authorization.A photocopy of this relcasc hall be as valid as he original.

I havc thoroughly revicwed this application and have answcrcd all qucstions to the best of my knowlcdge. By signing below,I hcreby agree o all mattcrs 6ct fortb above and bclow, including, a mutti-company assignment of commissioni set-forth inPan VItr and dre acknowlcdgcmcnt authorizations and releases eet onh in Pan V-

I hereby agree that if and when any or all of the companies ssuc to me any Conuact(s) for which I hereby apply, I will bebound by such Conuact{s) (lndepcndent Producer Contract on form number CNI-550 for TOLIC, or Ageni CLntract onform numbcr CNI-500

for TOLIC, or on Non-lndividual Ageot Contract form nu-Erber CNI-525 for TOtlC. I understandthat my supervising office has specimen forms of the Crcntract(s) on file and I havc had the opporrunity to review suchContract(s). My submining to the company any application for an insuraoce policy or annuity contract shall con$titute myagrement to such Contract(s), and all of the tens, cooditions, and provisions set forth thctcin. I acknowledge that bysigning rhis Conrract-Application and by submining aoy such nsurance application for an insulance policy or annuiry conuact,I have so agreed o the Contract(s) and no {urther signature by me shall be necessary.

I havc becn provided with pages ive (5) through ten (10) of this application, for my records.

Applicaot Signature Date

GA Signature

TOA 56-110s Pagc 4 of 8

Datc


5/14

The Applicant, hcreinafter called the Assignoq for value rcccived, assigos o Transamerica Occidental Life InsuranceCompaly aad Transamcrica Life lnsurancc Cmpang and to any othcr company which is a subsidiary or a6liatc of TrauamericaOccidental Life Insurancc Company- Transamerica Corporation or Transamcrica Insurance Corporation of Califomia,individually and collectively rcferred to herein as Assigncc or Assignecs, heir successors end assigns, all of thc Assignor'srightr, title and interest in and to any and all commissions and other compensation of any nature whatsoever now due andpayable or hereaftcr to bcome due and payable under the terms of any and all agency contracts and commission agrccmcnrs,now or hcreafter existing, bctwcen thc Assignor and each Assignee,

This Assignmcnt is given to secure hc payment of any presertt or future debit balance n the Assignor's account with cachAssignee and any othcr prcsent or future indebtedness of thc Assitnor to each Assignee. Notwithstanding anything to theconEary i! any othcr agreement heretofore or hercafter cxccutcd betwecn the Asignor and any Asigace, it is expresslyageed, but lot by way of limitatioo, that the foregoing includcs repayment of advances against commissions heretofore orhereafter giveo to the Ascignor by any Assignee oward repaymcnt of such advances and iqterest,

This Assignment shall be subiect without exception to thc tcrms, limitatioos and conditions of said ageocy crntracs aadcommission agreements and to all rights thereunder of thc Assignccs, heir successors and assigns. Notwidrstanding thisAssignment tbere s rcscrvcd to cach Assignee, s successors nd assigns, he right to offret against said commissions aad othercompeosation any and all advances rom dre Assignees o thc Assignor and any indebtedness without cxception ofthc Assignorto aoy Assignee now existing and such other and futurc indebtedriess which any Assigncc, ts succssors nd assigns, would

have been authorized to dcduct ftom or of6et against said commissions or othcr compensation payablc to thc Assignor if thisAssignmcnt had not bcn madc, If the Assignor is or hercaftcr becomes nsured under or covered by any group insurance,pension, etiremeng defcrred compensation or other bencfits plan, or any policy plan providing errors and omissions protectioaor simi.lar insurance, provided by any Assigaee or its agents o! utilizing any Assignee's accounting facilitics, thc Assignorreserves he right to authorize any Assignc, or to continue any existing authorization, to deduct from ssid commissions andothe! compensation the Assignorb premium or other coutdbutions to or for such plans and policies and to authorizc incrcascsin thc amount of such dcductions.

It is the intent of this Assignmcnt that aay Assignce rcceive and retain the commissions and other compensation whichare the subiect of this Assignment only to tie extent neccssary o secule reFryment ofany present or futurc dcbit balance n theAssigootb account with such Assignee and aay o&er prcscnt or fufure indebtedness f 6e Assignor to etrh Assignce. Thcrcbrgnotwithstatding anything to thc contrary herein, cach Assignce s hereby authorized and directed to pay all commissiqns andother compcnsation in thc Assignor's account witb such Assigncc o the Assignor for his/her own usc and pu:rpose unless aodqtil an Assigncc dctermines that it is necessary o cnforcc thc termc of this Assignment to plotect its inierect itr sucb debitbalances aud ottrer indebtedncss within the intent of this Assignment.

Each Assignee r hereby authorized and directed to pay all comrnissions and otler compeusation helcby assigned directlyto any other Assignee, unless aod until ir receives a written releese of this Assignment.

All Assignees are hereby authorizcd to lcceive any moneys now due aud payable and which may becomc due andpayable uader the above indicatcd agency contracts and cosurission agrccmcnts. The Assignor hcrcby ratifies any acts thatany Assignee may rnake in connection with this Assignnent.

It is istended that the provisions of this Agreemetrt be construed irr the same manner as if thc Assignor bad executedseparate assignpeats ia favor of each of rhc companies hat consdtutc er Assignee hsreunder.

TOA 56&1105 P.gc 5 of 8


6/14

Under currcnt tax laws, you arc required to give us your corrcct TIN (either a Social Security Number (SSN) or EmployerIdentification Number (EIN).

The lnternal Revenue Services IRS) uses he TIN for identification purpoees and to hclp verify the accuracy of your taxrcturn. You must provide your TIN whcthr or trot you arc

lcquLed to filc a taxrcturn.

Transamerica must gcncrally withhold 31ol" of your commission payments if you do not givc us a correct TIN. Certainpcnalties may also apply. Following arc some general guidclines:

a Individuals: If you are an individual, you must provide the name shown on your social security card.Howcveq ifyou have charged your last na.me e.g. duc to marriege) without informing thc Social SecurityAdministlation, please eotet you! fust name, the last name shown on your social security card and yournew last name.

. Sole Proprito(s: You (the owDer) must provide your individual aame al it appea$ on your socialsecurity card. You may also provide your "doing business as" narne. You may use eithcr your SSN orEIN. Show the name that appcars oa your social securiry card and the busincss name as it was used oapply for your EIN or Form SS-4. Please note rhat usc of aa EIN may result in unnecessary RS noticcsbeing sent to Transamerica by thc IRS.

. CorPontion aod Parbcrships: Provide us the namc and EIN of the partnership or corporation-

lf you do not have a TIN, you must rcqucst onc ftom the Social Security Administration by using Foro SS-4 for EINs)or SS-5 for SSNsl.

tl Additiolal inforrnation to any "Yes- answers,l Copy of currcnt resident licenscO Copy of nou-resident Ucense(s)tl Supporting docunentation, i.c., court records,l Voidcd check or savings deposit slip for Auto-Pay

TOA 556-1 05 Pagc 6 of 8


7/14

Pare informacion en esp6tol, nisi? unttro.ftc.goulaedit o esaibe a Ia FTC Con*mu Response Cetrt4Room 730-A 600 Pennsyhtania Aae. N.W,, Washington, D,C. 20580

6 5.-'-'sy of Your Rights Under the Fair Credit Reponing Act

The federal of Your Rights Under the Fair Credit Reporting Act (FCRA) promotes the accuracy, aimess,and privacy of information in the files of consumer reporting agencies. There are many types of consumerreporting agncies, ncluding credit bureaus and specialty agencies such as agencies hat sell information aboutcheck writing histories, medical records, and rental history records), Here is a summary of your maior rightsunder the FCR.A- For more infonnatiou, includiag iaformation about additional rights, go to www.ftc.gov/credit or write to: Consumer Response Center, Room 130-Ao Federal Trade Commission, 500 Peonsylvania Ave.N.W., Washington , D,C. 20580.

. You must be told if hformation in your file has becn used against you. Anyone who uses a credit report oranother type of consumer epon to &ny your application for credit, insurance, or employment- or to takeanother adverse action against - you must tell you, and must give you the name, address, and phonenurnber of the agency hat provided the information.

r You have the rigbt to know what is in your file. You may request and obtain alt the information about youin the files of a consumer eporting agency (your 'file disclosure"). You will be required to provide properidentification, which may include your Social Security number. ln many cases, he disclosure will be frec.You are entitled to a free file disclosure f;

r a person has taken adverse action against you because f information in your credit reporq. you are the victim of identify theft and place a fraud alen in your file;r your file contains inaccurate nformation as a result of ftaud;a you are otr public assistance;. you are unemployed but expect to apply for ernployment within 60 days.

In addition, by Scptember 2005 all consumers will be entitled to one free disclosure every 72 months uponrequest from each nationwide credit bureau and ftom nationwide specialty consumer reporting agencies. Seewww.ftc.govlcredit for additional information.

o You have thc right to ask for a credit score Credit scores are numerical sunnraries of your credit-worthi-ness based on information from credit bureaus. You may request a credit score from consumer eportirgagencies lat create scorcs or distributc scores used n rcsidential real property loans, but you will have topay for it, ln some nortgag transactions, you will receive credit score information for &ee from themortgage lender-

. You have he right to dispute nconplete or inacclratc information. If you identify information in your filethat is incomplete or inaccurate, and report it to the consumer eporting agency, he agncy must investigateunless your dispute s frivolous. Sec www.ftc.gov/credir for an cxplanation of dispute procedures.

a Consumer rporting agencies must conect or delete naccurat, incomplet, or unverifiable information,lnaccurate, incomplete or unverifiable iaformation must be removed or corrected, usually within 30 days.However, a consuner reporting agency may continue to report information it has verified as accurate.

r Consumer reporting ageEcies mry not report outdatd negative nformation. In most cases, a consumerreporting agency may not report negative information that is more than sevcn years old, or bankruptcies

TOA 556-1105 Page 7 of 8


8/14

Access o your file is limited. A consumer reporting agency may provide information about you only topeople with a valid need - usually to consider an application with a creditor, insureq employer, andlord, orother business. The FCRA specifies lose with a valid need or access.

You must give your consent or feports to be provided to employers. A consumer reporting agency may notgive out information about you to your employer, or a potential employeq without your wxitten consentgiven to the employer, Written consent generally is not required in the tucking industry. For moreinformation, go to www.ftc,gov/credit.

You may linit 'lnescreened' offers of credit and insurance you get based oo information in your creditrePort Unsolcited "prescreened" offers for credit and insurance must include a toll-ftee phone numberyou cal call if you choose o rcmove your name and ad&ess from the lists these offers are based on. Youmay opt-out with the nationwide credit bureaus at 1-888-OPTOUT 1-888-567-8d88).

You may seek damages roE violators. If a consumer eponing agency, og in some cases, user of consumerreports or a furnisher of information to a cotrsumer reporting agency violates the FCRd you may be ableto sue n state or federal court.

r Identify theft victims arrd active duty ofitary personnel have additional rights. For more information, visitwww.ftc-gov/credit.

States may enforce he FCRA, and many states have hcir own consumer eporting laws. In some cases, ou Erayhave more rights under state aw. For more information, contact your stat or local consumer proteclion agencyor your state Attomey General, Fedcral enforcers are:

TYPE OF BUSINESS: CONTACT:Coasuoer rcporting agcocies, crcditore and others oot listedbelow.

Fcderal Trade Coro.oission: Consumcr Reoporuc Ccnter - FCRAVashiryton, DC 20580 1-877-3824357

National banlts, fcderal branchesy'agcncies f forcign banks (word"Natioaal" or initials 'N.A." appesr in or after bank,E natr'e)

Office of the Comptrollcr of the CurrenryCompliancc Manageoeut, Mail Stop 6-6!0ashingon, DC 20219 800-673-6743

Federal Rescrvc Systcm membcr banks (exc.pr letiolal banks,and fedcal braacheJagencies of forcign benls)

Fcderal Rcserve EoardDivision of ConsuEcr 6c Comnudty A-ffairsW.shingtor! DC 20551 202452-3693

SaviDgs ssociations rd fuerally chanered aviugs alks (wod"Fcderal" or initiale "F.S.B," ppear n ledcral nstitution's rema

Office of Thrift SupervisionConsumer CooplainoWashington, DC 20552 800-842-6929

Federal credit unions (words 'Fedcral Crcdit Uniol. appcar ininstitution's nemcl

National Credit Union Administradon1775 Dukr SEcetAlcxandria, VA 22314 703-519-4600

State-chancrcd banks thar are not mcrabcrs of rhe FedcralReserve Systcm

Fcderal Dcposit lnsurancc CorporationCorrsurn.r RcslroDsc Ccntcq 2345 Grand Aveoue, Suitc 1 00Kansascty,Missouri6410S-2638 7-877-275-3342

Air, surfacc, or rail common carricrs rcgulatcd by formcr GvilAeronautics Board or Inrcrstarc Courmcrce Coooission

Departrncnt of Transponadon, Office of Financial ManagcmcntVe8hington, DC 20590 202-366-1306

Activities subicct to thc Packers aod Stockyald6 Act, 1921 Dcpartment of AgricultureOfficc of Deptty Admin;tator - GIPSAVashington DC20250 2O2-7ZO-7OSL

TOA 558-1105 Pagc 8 of 8


9/14

|,.,'.., D Tr.rsrm.ricr Occidcntal Life Iniurenc. Corlpary

E IRANSAMERICAErraasamcricalirckrsurancecompanv

Eo INSUMNCE & INVESTMENTGROUP CdarR;i&, tA 52499

Auto-PayAuthorization

GAName: Of6ce D,-

This secrioo euthorizes Tralrsacrerica Occidental Life Insurance Compaay/Tmacamerica life Iosurance Gompany todeposit your bi-weekly commissions nto your drecking, money market or savings account- For a checkiug or uoneymarket account, please nclude a voidcd check or deposit slip. For a savings accoung please ndudc a deposit slip.

I hereby authorizc Transamerica Occidental Life Insurance Company/Iransamerica Life Insurance Company (hereaftercallcd the Company) to initiarc dcposits (crcdits) and./or rnmcdiate/same day corrections to dcposits, iI proccsscd ncrrog to the fiaaocial institution indicated below. Tbe fioaocial institution is authorized to credit and/or correcr thea&ounts to my account, This autbority is to remain in full force and effect until the Coupany has rcceived writtcnnotification ftom mc of its teruhation in such timc and such manner as o afford thc Company and Financial lastiti-tuion a reasonable ppomrniry o act on it.

Note: The CompaDy will not utilize thiE authorization to collcct outstanding balanccs owed to the Company. Alter-native rep4yneot methods must be established benveen you and the Company in accordance with the terms of ourcontrac,tual agreement

Your NaEe: Your Ageut D:

Social Security Numben

Prderred Addrers:City

E-mail Addrcss:

St tc Zip Code

Prefcrred Phonc #

Fbaocial Institution Name:

Fbarcial Institution Address:Streei

Che&ing or Savbgs Account Nuober:

City Starc

EFT Traasit/ABA Numbec

Zp Cade

Account Types: E Chccking/Money Market E S"viogs

Your Signature

a If thc namc on thc banl eccount is diffcrelt 6om thc cootractcd pcrson or entiq, a signature &om the accountholdc. or sigohtofFccr of dte account (iI a corporarion/frm) is rcquircd.

ttAccounrboldcr's Signarurc (If signing officer of corporation/firm) Datc

rflil]llltriliOA s&208 rDc54r


10/14


11/14

MetLifc I ndependent DistributionProfile Fornr

\ l l . Il \ lSA StatementTh e N4etlife l 'fi l iatednsurancc onrpanies VlelLifelare onrnrilted o conducting usiness vith he highest rhical ndlegal tandards. 'e have stablislred tradrtionol ntegrit) ndealin-r$irhourcustonlers let[-ile has adopl! 'd he eihical

marketofconductprogra of thelrsufance\ larketplaceSt!ndards . \ssociat ior1l l lS , ,\ ) . , \ sdescr ibedbelo\ \ . \ le ll i fe .a t lemployees nd distribrlors rc c\peclcd b observe he Principles nd Code ot ltlS-{:

l. lo conducl Ltsiness ccording o hish standards fhoncsl) and airness nd o rcndcr ha l scrvicc () ou rcustomels hich. rr he santc ircurrstance. ve rould appl\ to or demalld ir r lsclf.

I -l o provide onipeteut tnd uslt)nter-lbcused alcs nd s! '1.\ ' ice.-l . To engage ll active nd aif courperition.1. -l o proride advertisirrg nd sales matrials ha t re clear as o purpose nd ronest nd ai r as o conl( 'nl.j . To pro\ide br fair an d erpeditious andling fcusrourer orlplai ts and disputes.6. To maiDlaifl systenr fsupcrvision nd evierv ha t s rcasonably esigled 1oachieve onrpliance vith

these finciplcs ferhical nrarker onduer.

VllI- Ackno\iledgemcnt:r | |dAuthorizaiiotlIh. 'reb) cerlil-\ hnt h!\c rctd and unJclslarrrlhc tcms or) his appoi|l lncnl brnr and hat nrr ans$ers re rue andcomplele o hc best f rny norr cdge. hare been dviscd hat letlife. lnc.. lciropolitan. Ceneral \nrcrican. lalnul

Slreel Securilies. letlife IIvcitors. and Ncu'lingland Financiil ardiheirnftlliatcs(hereafiefreferredtoas l 'heConrpal)ies Ilra\ conduc( riv.stisatious r ronncctron irh nt) fequest o feprese0r he ( oIl]pa0ics n dte s0liairirion lcertain nsurance roducls. authorize rn nquir) ' tr) e nlade fall soufces ecured pproprialc ) 'The Conlparries or tlrepurpose fobtaining nfornlalioll oncenlirrn rt trusiness r 'actices nd ethics. ackgrouud. rcdithiston. and inancialstatus. ncludin{,but not il l i tcd to. nr! rccord. fan}. on tjle \itlr th e FNR.{ Cenlral Records eposilory. \n)infomration ha t -h e Cofipanies r.r) obtairr boLrr e will be reated s corrfldelltial nd may be shared vith he appointirrggerteral geDl. f nccessan'. release he broker dealer nd r' ts agents nd an ) persoD r cltti t l rvhichpror' idc nformationprrrsuant o his arrtho|ization.ionr anl an d all l iabilnics. laills or la$suits n an\ nratter elnted o e inlb |ationoblained ronr any and allofthc abole relirenced ources sed o th e exrent ernritted y law.

I undetstand hat no right o corlrnrission r olher conrpensalion hallarise r exist until I ha\e been appoillled nd all duediligence ucccssiirll)- pprovcd, f I anr apprlved. shall acccpr s ull ron)pensation or all ser\, ices o b c perlbrnlrd h)nte. he colnpensalion roridecl n the ipplicable omurissi(rn nd onrpensation chedule s ssucd. bstitutcd r chaDge(lAs an appornlcd gen!brokcr. shirllobser\c trd be bould bt tlrc ulcs and cgulillions f lhe Cornpanies.

I a{ree o conduct \ business a.cordance ith he \lS.{ PriIciplcs t l : thical larker ( 'o,lducr.

CorDorate:

Name please ritri egiblv Signature Date

\ar le (please r i r r l eLrbl \ Sig JtLrrc Da!e

Prolile Fonn 3,r:007)


12/14

D/SCLOSURE

By his document. ,4etLifenc . and all affiliates hereafter eferred o as "The Companies') isclose oyo u that a consumer eport or an rnvestigative onsumer epod containing nformation s to yourcharacter, eneral eputation, ersonal characteristics nd mode of living. may be obtained oremployment purposes andlor in connection with your application r request o represent Th eCompanies n the solicitation f certain roducts nd services. consumer eport or an investigativeconsumer eport may be secured as paft of a pre- employment nd/or pre-appointment ackgroundinvest igat ion nd at any t ime during our employment nd/or ppointment. hould n invest igat iveconsumer eport be requested. ou will have he right o demand a complete nd accurate isclosureof he nature an d scope of th e nvestigation equested. nd a written ummary fyour ightsur]der heFair CreditReporting ct

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge eceipt f a separate ocument etting orth he above disclosure y MetLife nc. andall affiliates hereafter eferred o as 'The Companies that a consumer eporl or an investigativeconsumer eport may be obtained y Th e Companies or employment urposes nd/or n connection

withyour application r request o represent he Companies n the solicitation f certain roducts ndservices. consumer eport or an investigative onsumer eport may be secured as part of its pre-employment nd/or pre-appointment ackground nvest igat ion nd at any time during nryemployment nd/or appointment. authorize he procurement f such consumer epofis by TheCompanres or the purposes isclosed o me. lf I a m hired and/or appointed, r if I am alreadyemployed nd/or appointed. his authorizat ion i l l remain on f i le and wil l serve as an on-goingauthorization he Companaes o procure uch consumer eports t any time during my employmentand/or pporntment.

I hereby uthorize n inquiry o be made of all sources eemed ppropriate y The Companies or hepurpose of obiaining nformation oncerning my business ractices nd ethics, background. redithistory, and financial tatus. ncluding, ut not limited o, my record. f any. on file with the FINRACentral Records Depository. Any informationhat The Companies may obta in about me wi l l betreated as confidential nd may be shared with th e employees. gents, or general agents of TheComoanies. f necessarv

Any copy of this Authorization hallhave he same authority s he original.

t r I would l ike to receive a copy of atry consunrer eport or invest igat ive onsumerreport eceived y the Conlpanies.

hrr ing vlanageis a 'ne

Pf lnled Narne of Applican!rEmpi.yec

!Mtness Sgnature

Prinled Name cf Vvitness

Reform cl EmploymnURegistrat ion rsc sure/Auhor al ton


13/14

D/SCLOSURE

8y this document, MetLife nc and all affiliates hereafter eferred o as "The Companies') isclose oyou that a consumer eport or an invest igat ive or ' rsumereport ontaining nformation s to yourcharacter. eneral eputatjon. ersonal characteristics nd mode of living,may be obtained oremployment Lrrposgs nd/or n connection i th your applicatron r request o represent heCompanies n the solicitation f certain products nd services. consumer eporl or an investigativeconsumer eport may be secured as part of a pre- employment nd/or pre-appotntment ackgroundlnvestagatron nd at any time during your employment nd/or appointment. Should an investigativeconsumer eport be requested, ou will have he right o demand a cornplete nd accurate isclosureof he nature and scope of the nvestigation equested. nd a written ummary f your ights nder heFair CreditReporting ct.

ACKNOWLEDGMENT AN D AUTHORIZATION

I acknowledge eceipt f a separate ocument etting orth he above disclosure y lvletLifenc . an dall affiliates hereafter eferred o as Th e Companies that a consumer eport or an investrgatrveconsumer eport may be obtained y The Companies or employment urposes nd/or n connection

withyour application r request o represent he Companies n the solicitation f certain roducts ndservrces. consumer eport 0r an investigative onsumer eport nray be secured as part of Its pre-employment and/or pre-appointment ackground nvestigation and at any time during myemployment nd/or appointment. authorize he procurement f such consumer eports y TheCompanies or the purposes isclosed o me. lf I am hired and/or appointed. r if I am alreadyemployed nd/or appointed, his authorizat ion i l l remajnon f i le and wi l l se rve as an on-goingauthorization he Companies o procure uc h consumer eports t any time during my employmentand/or ppointment

I hereby uthorize n inquiry o be made of all sources eemed ppropriate y Th e Companies or hepurpose of obtaining nformation oncerning my business ractices nd ethics, background. redrthistory, nd financial tatus including but not limited o my record, f any, on lile with the FINRACentral Records Depository. Any information hat Th e Companies may obtain about me will betreated as confidential nd may be shared with the employees. gents, or general agents of TheCompanies. f necessary.

Anycopyof hisAuthorizat ionhal l ave he same authori ty s he original .

Hrnng Manageis ame Signarure f Applicant /Ernployee

Prnled Name of ApplicanvE pl o ee

Printd Name ol Wtness

ReiormAct Emp oynrenVRegrstralron sc osure/Authorizaton


14/14

MLl. this Agtccnrcrrt hallbc gorcrned r thc arrs of th,,. tatc l Delarrarc rithout egard oDelauare hoicc f larr ules.

Section 0.l"l. Jurisdicrion. \ itlt rcspL"cto an\ acrion. uit or other proceeding enreen ll-lCan d Brokcr. ach ofthc Partics rrevocablr nd unconditionally ubnrits o the non-cxclusiveiurisdiction f tlie Lnit,, 'd tates istrictCourt orrhe Sourlrern istricr fNe\ \'ork or. f suclrcoun sill not accepr iurisdicton. he Suprcrlc Coun ofthc State fNes, York or anl,coun olcompetent ivil.!urisdiction itting n Neu York County. Ne l York. \\/ith respccr o an)- crion.suit or other proceedinl etrveen \4Llan d Broker. ac h l the Parties rrevocabll an dunconditionalll ubrnits o tlrc non-cxc us ve urisdict orrol'thL'Llnilcd tatcsDistrictCoun orthe SoLlthern istr ict l Dclat iate r. 1 'such r.rul t i l l not rc ccpt . iurisdict ion.he Superior ourtofthe Stare f Delau are r an,\,coun fconrpetent ivil.jurisdiction itting n Delawa re. nanvaction. ui tol other procecdint. aclr l'the Parties rre\ocabl\ and ,rnconditionallrraircs anclagrees ot o asseft y \\a! of motion. s a defensc r olhenvise n; clait'l]sha t t is not subjectto the iurisdct on ofthc above ourts. hat such action r suit s brought n an trconvenienttbrunror that hc .enuc fsuch acrion. ui to[ other procceding s improper. Eaclr fthe ltanies

hereby grees ha t any inal and unappca able iudgrrent gainst Party n connection ith ant-action. uit or olher procectling lrallbc tinal an d binding n such Partr and hat such a\ard orjudgenrent ay be entbrced n any court o,'comperent urisdiction. itherwithinor outside ftheUnited tates . cert i l ied r cxcmpli l icd opvol such *ard or. judgment ha l l e conclr. rs ivcevidence fthe l:rctand ar'lloul'ttfsuch auard or'.judgrrrent.

Sect ion 0.15. {orl \ \ 'cDo Business Lridc. roker ckrrowledgcshathc or she as eccivcclMetlit'e's How We Do Business uide. he ernrs f uhich are ncorpomted ercin l reltrcnce.and agrees o compll rr th hc rules an d equircnrcnrs ct orth n \lctLilt s Hou We DoBusiness uide.

METROPOI,ITAN ,IFEINSURANCICOMPANY

PrintNanre f Broker

-fitle: 'I itl! ':

Date:ddress:

aI

SocialSccuritv o.:NIETLII. INVISTORS USAINSLJRANCtT OMPANY

B ':

0r 'faxpal er D No.

Date:

Titlc:

t4

Date:

Documents

Trans America Contracting