PLEASE NOTE: License papers MUST accompany your first new business ...

Individual

PLEASE NOTE: License papers MUST accompany your first new business application in all states EXCEPT Pennsylvania. Pennsylvania agents MUST be appointed PRIOR to submitting new business. ERRORS AND OMISSIONS coverage is required.

ANTI-MONEY LAUNDERING

As you know, Anti-Money Laundering training for insurance agents is a Federal requirement. Once you have taken a "base course", you should be taking an annual "refresher course". All insurance companies are obligated to enforce this requirement. This information must be provided to the insurance companies in order to complete your licensing and contracting request.

Please indicate below where you take your Anti-Money Laundering training:

_____ LIMRA (accessed on-line via aml.). You won't have a completion certificate. The insurance companies can verify directly with LIMRA.

Date last refresher course taken: _________________________

_____ OTHER (such as thru your broker/dealer, bank, RegEd, Kaplan, or other vendor) -Please attach a copy of your latest course completion certificate.-

Agent Name: ____________________________________________

SPECIFIC SOLUTIONS, INC.

TO SERVE YOU BETTER, WE NEED THE FOLLOWING INFORMATION TO COMPLETE YOUR PERSONAL FILE IN OUR COMPUTER SYSTEM. IF YOU HAVE NOT PREVIOUSLY COMPLETED THIS FORM, PLEASE SUBMIT IT WITH YOUR LICENSE PAPERS. IF YOU HAVE COMPLETED A FORM FOR US, PLEASE NOTE ANY CHANGES.

q NEW AGENT

q UPDATED INFORMATION

PLEASE PRINT OR TYPE

DATE:__________________

1. Producer is: q Individual q Corporation q Partnership

2. Name of Producer:________________________________________________________________________________________________________________ Birth Date:_______________________ Soc. Sec. No.____________________________________ or Tax I.D. No.___________________________________

3. Business Address:_________________________________________________________________________________________________________________

(STREET)

(E-MAIL ADDRESS)

_______________________________________________________________________________________________________________________________________________________

(CITY)

(STATE)

(ZIP)

(BUS PHONE)

(FAX NUMBER)

4. Residence Address:________________________________________________________________________________________________________________

(STREET)

_________________________________________________________________________________________________________________

(CITY)

(STATE)

(ZIP)

(RES PHONE)

(CELL PHONE)

5. How would you like case status delivered to you?

q Mail

q E-Mail

6. Designations: q CLU q CHFC q CFP q CPCU

q RHU q CPA q OTHER:___________________________________

7. Business Status:

q Full-Time

q Life

q Property/Casualty

q Securities Series

q 6

q 7 q 26

q 24

8. Name of Employer, Agency, Primary Company, or Broker/Dealer:___________________________________________________________________________

9. If Partnership or Corporation, list all members to be appointed:

Corp Name:__________________________________________________________ Tax I.D. No:__________________________________________________________

Name

Title or Position

Residence

Birth Date & SS# DOB:

Securities License Series q 6 q 7 q None

SS#: DOB:

Securities License Series q 6 q 7 q None

SS#: DOB:

Securities License Series q 6 q 7 q None

SS #:

10. Have you ever had your insurance or securities license suspended or revoked?

q YES

q NO

If "YES", explain:__________________________________________________________________________________________________

11. Do you have E & O coverage? _________________________________ Amount:_____________________________

PLEASE NOTE: WE MUST HAVE A COPY OF YOUR CURRENT MASTER LICENSE ON FILE. IF NOT PREVIOUSLY SUBMITTED, PLEASE ENCLOSE WITH THESE PAPERS!

PLEASE READ AND SIGN REVERSE SIDE -

IT IS AGREED by and between Specific Solutions, Inc. ("First Party") and the producer ("Second Party") that in consideration of First Party's continued good will and patronage:

A. First Party agrees that the commission payments, if any, made by First Party to Second Party shall be vested in Second Party to the same extent that commissions on the same transaction are vested in First Party by applicable insurance company, with the exception of group insurance which may be subject to Broker of Record direction.

B. Second Party agrees to hold First Party harmless and indemnify First Party against any and all liability, loss, damages, judgments, costs or expenses of any nature, type or kind, including payments to First Party's attorneys, incurred by First Party or imposed upon First Party's agents as a results of any allegedly wrongful or tortuous omission on part of Second Party.

C. Second Party agrees to obtain and maintain from the date of this Agreement forward at Second Party's expense liability insurance coverage with a deductible of no more than $3,000.00 from an insurance carrier licensed to do business in the state of applicable jurisdiction. The insurance coverage will include protection against any errors or omission on the part of the Second Party and his or her agents and employees. Second Party will be listed as the named insured. Second Party agrees to provide proof of such insurance to First Party with a copy of the applicable insurance policy (or policies) upon the request of First Party.

D. In the event that any commission, premium, or fee paid or credited to Second Party must be refunded or returned by First Party to the insurer, First Party is authorized, but not obligated, to make payment on Second Party's behalf, and will be reimbursed for this payment in full by Second Party within thirty (30) days of the date of such payment. If such payment is not made by Second Party, then First Party is authorized to debit any commissions which may be due to Second Party until such obligation has been fulfilled and the obligation from Second Party to First Party has been extinguished. Second Party will also reimburse First Party for any and all costs and expenses including, but not limited to, reasonable attorney's fees, incurred by First Party in collecting any such sums from Second Party.

E. Second Party certifies that information provided to First Party in this Agreement is correct and complete.

Date:___________________________ By:______________________________________________________ SPECIFIC SOLUTIONS, INC. ("FIRST PARTY")

Date:___________________________ By:______________________________________________________ Producer ("Second Party")

CONFIDENTIAL DATA SHEET INDIVIDUAL APPOINTMENT APPLICATION ? LIFE INSURANCE

Type of Contract - Please check applicable boxes. Individual (Include signed Broker Agreement)

Selling on behalf of a firm, complete firm information, "Section "C

If selling on behalf of a Broker Dealer with compensation being paid to the B-D, complete "Section D"

A. Producer Information ? Complete all fields or mark N/A.

Last Name

First Name

Middle Name

Social Security Number

Date of Birth

E-mail Address

FINRA CRD# (if ever registered)

Business Address/Suite/ P.O Box

City

State

Business Telephone

Fax Number

Home Address

City

State

List State(s) to be appointed

Florida non-resident appointments, list counties

Zip Mobile Number

Fixed

Zip Variable

B. Errors & Omission ? Required only if contracting as an individual.

Yes

Policy Number

Amount of coverage

Carrier Name

No

C. Firm Information - Complete this section only if selling on behalf of a firm. ** Important** A separate firm CDS is required when contracting and/or appointing a firm.

Firm Name

FEIN or Contract No

Address

City

State

Zip

D. Broker Dealer Information ? Complete this section only if selling on behalf of a Broker Dealer.

Broker Dealer Name N/A

B/D FEIN or CRD Number N/A

E. Brokerage General Agency (BGA) Information Section ? Complete all fields.

BGA Name Specific Solutions, Inc

BGA Contact Laura Mazur

BGA Phone 716-632-7777

BGA Contract Number AGY699

BGA E-Mail Lmazur@

F. New Business Information Section ? Complete all applicable fields.

Have you submitted new life business with this appointment request?

Yes

Name of proposed insured:

State:

No.

Important - If there is no new business and the appointment is being requested in a jurisdiction that allows

concurrent submission, the appointment request will not be processed but will be held for 90 days from the

date the CDS was signed.

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NR-000004 Ed. 12-15 Ord. 112175 Rev. 12/2015

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