ASSURANT Health Fonn Transfer 09-05

tJ ASSURANT Health

. .General Aaent I ARent Transfer Form

Fonn GA-AGT Transfer 09-05

I,

Name of transferring General Agent or Agent

, am ~cjIuesting a transfer

From

Name of current RSD, MGA, GA

To

Name of new RSD, MGA, GA

.I understand that: No transfer to another Time Insurance Company ~gement

will be approved within 180 days of the initial

. appointment or date the last transfer was effective. This transfer will not go into effect until a date sel

and approved by the Company which will follow the

. ~~ receipt of proper notification by the current arrange e l Any applications solicited prior to the date approve the company will be credited to my current arrangement,

i.e. the "From" relationship listed above.

. .

_ i I understand and agree that any business written

my new arrangement in any manner. This includes I understand that my total compensation as a gener exceed %. (This includes any incentive bonus

my current arrangement will not be transferred or moved to

uests from policy owners for a new agenl ent or agent on individual major medical business will not

bursements for leads or any other forms of

reimbursements).

Failure to comply with the rules stated above will be dee a violation of the Company's policies and an act harmful to the

~ best interests of the Company. This will result in' ediate termination for cause of my general agent or agent

arrangement with Time Insurance Company and forfei of any remaining first year and/or renewal commissions.

Signature of Transferring General Agent!Agent

Home Office Use only:

I Date Received

Initials

in LCS

Date Received inSaIes

Initials

Notification Date

Date Signed

Initials

Transfer Date

Initials

Products are underwritten and issued by:

Time Insurance Company

501 W Michigan

Milwaukee, WI 53201

1ime InsuranCE

~MGA

Cl1anne~ARentTransfer Rules

. LCSRULE5-04

1. Agents must remain in their current arrange .t f'Or180 days bef'Ore a transfer request will be

c'Onsidered.

,flfirstTime Insurance C'Ompanyapp'Ointment) will

2. New agents (license received within 90 days n'Otbe transferred f'Or'Oneyear fr'Omtheir st

ate with Time Insurance C'Ompany. (General

Agent/MGA must n'OtifyAgent License and .tract Supp'Ort'Ofnew agents by c'Ompletingthe Initial License N'Otificati'OnF'Ormand submi g it with app'Ointment paperw'Ork.)

3. Agent Transfer Requests must be submitted F'OrmGA-AGT Transfer 5-04. Inc'Ompletef'O

'Oughthe new arrangement using Agent Transfer will be returned.

4. We will n'Otifythe current RSD, MGA 'OrGA an agent's intent t'Otransfer when we receive a

pr'Operlyc'Ompletedtransfer f'Orm. 5. The effective date 'Ofthe transfer will be the a e established by the C'Ompany.

6. C'Ompanypaid-direct agents with an 'Outst . g debit balance will n'Otbe transferred until it is res'Olved'Orthe new arrangement agrees t'Oa s e it and have it transferred al'Ongwith the agent.

7. We will n'Ottransfer any business written

gh the current arrangement.

8. Transfer requests f'Oragents app'Ointed thr'O a Nati'OnalAcc'Ountmarketing arrangement will

n'Ot be h'On'Ored.

9. Y'Oumay d'Ownl'Oadall f'Ormsand app'Ointm healthsales.us.f.Ortis.c.Om.

paperw'Ork fr'Omthe Assurant Health web site at

10. Send transfer requests t'O:

Assurant Health Agent . ense & C'Ontract Supp'Ort

P.O. x 3183

Milwaukee ~~ 53201-3183

FAX request: 414-299-8471

Individual Medic om ensation Rules

1. A General Agent may n'Ottransfer f'Orhigher mmissi'On than they have qualified for. 2. N'OGeneral Agent may receive m'Ore than 25 o' t'Otalfirst year c'Ommissi'On. 3. N'OPr'Oducer 'OrWriting Agent level may rec i e m'Ore than 20% in t'Otal first year c'Ommissi'On. 4. A General Agent paid at 25% first year must ve a c'Ommitment letter f'Orthe appr'Opriate

pr'Oducti'On requirement. 5. N'Ocash reimbursements f'Orleads, expensesJIc~ntests 'Orincentives are permitted with'Out pri'Or

RVP appr'Ovai.

Products are underwritten and issued by:

Time Insurance Company

501 W Michigan Milwaukee, WI 53201

lime Insurance

tJ ASSURANT

1. MGA Name: 2. GA Name:

Health

Writing Agent/Producer Appointment Application for MGA's

Form MGA WA APP 09-05

AGENCY IN ,U "TION

11\GA Business No.

l A Business No.

4. Agent's Name (Full legal name):

INDIVIDUAL AGE il INFORMATION r ickname (Optional):

5. Social Security Number:

"I.Ke8laenr"

: ,Kequuea,

STREET

If. Date of Birth:

CTrY I STATE I ZIP (9 DIGIT)

8. Business Address: (Optional)

STREETor P.O. BOX PHONE E-MAIL

IJTYI STATEI ZIP (9 DIGIT) lAX I

. PHONE

- 9.Linicwehnisceh RyoeuquinirteemndentotsoperWatee. reF ................
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