Trans America Contracting

I r--.r

E TrrntamcricaOclidcotrl Lif. Irrdrrncc Company CONTRACTATPLICAIION FOR: Homc Office CcdarRaoids.lA 52499 E Ag€[t Cqrtraci (ftl-tin Carce(Ag.nt) AdmidstrerivcOffice PiO.box 419521 Kense!Gry, MO 64141-6J21 E IadepeadentProducerContract Frokcr) I Tran*ocrica Lifc lrrur.nc. Compeny El SalesDirector {epp[c,riotrrcqdredftr HomcOffic.: Ccd.r R.pids, tA 52499 individu.li mt or.raidy codrrect d drh AdminisEtiv€Oflicc:PO. Box4t9521 Trintiddic.l Kans$ City,MO 64141-6J21

E TRANSAMERIC"q, G. IT.SUn.ANCE 6.IN1I8STMENTGROTJP

Requesting GA Name:

Applicant is: O An Individual

Of6ceID: .-..-..'-................._ Date:_

O A Corporation

l_l

O A Partnership

I am requesting an agreementwith: 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 issuanceof a licenseand/or appoinment thc sol.icitation of applications on behalf of the company(ies). I understand that I may sot solicit -authorizing applications for tie compaoy (PleasescePart VI for additional provisions rcgarding al4rlic.nt's agreemcnt to bc bouud by the Agent aodl or IPC conrract or contracb).

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

Last Name:

First Name:

Middle Name:

Social Security Number:-------:----------:--. Do you plan to markct using a DBA? E Yes O No the supportitrg documentation, i.c., approval of required lurisdiction(s), DBA Name: pace six for gcneral (T (SeePage conccruine Taxpayet sctr€ral insttuctions conccruing TaxDaver Ideotification Idedtiftcetion Nuober Nunbet (TIN) IDforE tiotr.) Home Phoae #: ( L-BusinessPhone #: ( )

Ccll Phone #: ( Fax#: ( )

tr M! E Mrs. ! Mg D.O.B.-/BusinesVAlternate Addrcss:

Strcct How long at this residencc addrcss? -Ycare ResidenceAddress: Street

/_

-

If so, pleaseprovide

Pagcr#: ( Email Ad&css: Drivcr's License#

Statc:

city

Zip Code

Ciry

Zip Code

Stat€ Zip Code CirY Months If lessthan five ycars, pleaeeprovide past five years below:

CitY

Stete

Zio Code

Section B; {If applicantis e corporatior or partncrship,complctescctionB only). Parmershipor CorporateFirm Name: Do you plan to do businessas a DBA? tr Yes n No If so,please provide ttresopponing aoclffe'iAc*g,T.I,Tf,F3fft8l*t' required jurisdictiou(s), DBA Name: , and EIN for DBA if acquired (Seepage six for gcneral instructions conccrning Taxpayer Identification Number (TIN) Idormation) TOA556-1105

Pagc1 of 8

illlililtffiililtil 'D C 1?r

BusinessPhone#: (

)

Fax#: (

Address:Street Business/Alteruate

EmailAddress:

)-

Zip Code

City

Mailing/Primary Ad dtes* (if differentftom BushessAddrcss)

Name of person who will sign as principal of this organizatiou

Titlc

(PleasccompletePan Il SectionA for ptiocipal) (A SolicitorApplicetio! form TOA 560,rnurt be complercdfor edditioml priacipds audeigdrg of6ccrs,) givenamesof all ofliccrsandpriocipals,andtheir titlcs, If aeccssarnplcasccotrtinucon a seperateshectof papcr. For corporatiodparmership, (Plcasccomplaea SolicitorApplicationform for cachpcrsonwhowill solicitTraaramcicabusiness on bchalfof thccorpo..tion or p.rtncrsf,ip.)

NAME

NAME

TITLE

TITLE

1) How long have you bccn an insurance agent or broke!? Below, pleaselist the compa es that you currently reprcsent: Company Name:

Effective Date:

2) U this ioloruration covcrs lessthan fir'e years, pleaseprovide details of employment history to completc the five-yeaf period in the following section. Employer

Position

Address

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

Q Yes ONo

4) Pleaseprovide a copy of your individual ard/o! corpolate lcsidcnt Iiccnse(and/or a copy of your Letter of Certificatiou, if yolu resident statc requircs such). 5) Do you plan to solicit Transamcrica busincssin othcr iurisdiction? If so, arc you clrrendy licensed in O Yes E No thosc states? DYes E No If yes, plcaseprovide details i-ocluding copy(ics) of liccnse(s)for tho6e states. (Ple4sepfouide copy(ies)of non-tesidentlkease(s)dnd.setd non-residentf..s). lf. \ot, please be alr'ale that no solicitation of businessmay 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 businesson your behalf? O Yes D No. If so, please have cvcry employeesoliciting Transarncrica busincsscomplcte a Solicitor Application form.

TOA 556-'t105

Page2 ot 8

The following questions must be aaswered by the applicaoL ff the applicatt is a corporation or paruerqhip, tle questious apply to the fiIm and to each of its priocipals and officers. I/ yot ansuet YES to ary questions, pbase @n plcte alctaik dnd 4lat diaL on a wafltu sheet of pqer anil proaide seppotting doaonsntotion1) Have you ever bccn convicted of, pled guilry or no contest to a felony o! misdcmeanor? Note: you iray orrritrflisdemeanotcoivictions for possexioxof metijuanethat occvrteil mote than two yea6 dgo.

D Yes ENo

tt

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

O Yes ENo

J'

Have you, or any businessof which you were or plesently are a principal, been involved in a bankruptcy action within the last sevenyears? (If YES,pleaseattach detailedexplanationand a copy of the dischargepapers,if applicable.)

DYes

4l Have you been a plaiatiff or defendant in any court proceeding within the last sevenyearsl

QNo

Q Yes DNo

Nota Yor nay onit actiorLtintobhg tnattet of family laut,

5) Do you presently have, or have you ever had, aoy professional designations or membe$hips in

fl Yes

O No

industry organizationsl (If YES,pleaseprovidea list of suchdesignationsor ocmbetshipsandindicste datesof activity.) 6) Have you ever had any license denied, suspcndedor revoked, or bccn the subject of a disciplinary actiotr which resulted in a fine, penalry or restricted liccuse status? "LicenEe" shall include the following: a liccnse issued by a state insurance department, a state securities agency,the NASD, the SEC, or any other regulatory agency (or any other professional licettse or d,esignation),

E Yes QNo

7) Have you ever been discharged, or have you ever beenrequested to rcsign, from any enployment?

El Yes

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

O Yes ENo

9) Are there any outstanding judgments, liens, or gamishments against you, or any businessof which you wele o! pfesently are a principal?

EYes

QNo

10) Do you have urresolved matters pelding with the Intemal Reyenue Serviceor other taxing authorities ?

flYes

ENo

1 1) Does any insureg general agcut, agcnt, or broker daim you are indebted to it for unpaid prerniums, E Yes mishandling collateral, lossessustained, or any other rcason?

E No

tr No

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

E Yes 0No

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

E Yes ENo

Namc of Carrier: CoverageExp. Date -l_

l_

Amount of Coveragei_

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

Q Yes ENo

15) llave you everhad a bond declinedor canceled?

OYes

ENo

16) Are you currendy bonded?

OYes

ENo

TOA 556-1,t05

Pag. 3 of 8

Notice to PersonsApplying for SalcsRcpres€trtatiye Positions with Transamerica Occidental Lifc Iqsuralce Compatry and Tiansamcrica Lifc Insurance Cornmpany Federal law requires you be advised that in connection with your application to rcpres€trt Transamqica Occidental Life Insurancc Compaay and Transarncrica Life Inswaace Company (referred to as 'Transamerica" ) for the pu4rose of selling its products, a consumer rcpon andlor investigative consurner repon may bc prepared whercby information is obtained through credit reponing agenciesand./or pcrsonal interviews with your ncighbors, friends, or others with whom you are acquainted. Such reports are usually pan of the processof evaluating suitability for a salesrepresentativeposition. Inquiry may bc made into your character, general rcputation, pcrsonal characteristics, and modc of living and credit information. It is possiblc that a representativeof a firm employedto make suchreportsmay 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 Office made within a reasonable time after the receipt of this notice. A summary of your rights undcr thc Fair Credit Reporting Act is attached hercto. Authority for Relcascof Information To Whom It May Concem: I hereby authorize Traruamerica or its legal representative to obtain any information ftom former or curcnt cmployers, criminal justice agencies,consumc 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 dircct you to releasesuch information upon requestto Transamerica or its legal reprcscntativc. I undcrstand that Transamerica or its lcgal representativc may bc rcquircd by law to releaseinformation obtained to govemrnent agencies. I herebyreleaseall personsand entities,including recordcustodians,from any aod all liability for damagesofwhatevcr kind or nature which may at any tirnc result to me on account of compliance, or any anempts to comply, with this authorization. A photocopyof this relcascshall be as valid as the original.

I havc thoroughly revicwed this application and have answcrcd all qucstions to the best of my knowlcdge. By signing below, I hcreby agree to all mattcrs 6ct fortb above and bclow, including, a mutti-company assignment of commissioni set-forth in Pan VItr and dre acknowlcdgcmcnt authorizations and releaseseet fonh in Pan VI hereby agree that if and when any or all of the companies issuc to me any Conuact(s) for which I hereby apply, I will be bound by such Conuact{s) (lndepcndent Producer Contract on form number CNI-550 for TOLIC, or Ageni CLntract on form numbcr CNI-500 for TOLIC, or on Non-lndividual Ageot Contract form nu-ErberCNI-525 for TOtlC. I understand that my supervising office has specimen forms of the Crcntract(s) on file and I havc had the opporrunity to review such Contract(s). My submining to the company any application for an insuraoce policy or annuity contract shall con$titute my agr€ement to such Contract(s), and all of the tens, cooditions, and provisions set forth thctcin. I acknowledge that by signing rhis Conrract-Application and by submining aoy such insuranceapplication for an insulance policy or annuiry conuact, I have so agreed to the Contract(s) and no {urther signature by me shall be necessary. I havc becn provided with pagesfive (5) through ten (10) of this application, for my records.

Applicaot Signature

Date

GA Signature

Datc

TOA556-110s

Pagc4 of 8

The Applicant, hcreinafter called the Assignoq for value rcccived, assigosto Transamerica Occidental Life Insurance Compaly aad TransamcricaLife lnsurancc Cmpang and to any othcr company which is a subsidiary or a6liatc of Trauamerica Occidental Life Insurancc Company- Transamerica Corporation or Transamcrica Insurance Corporation of Califomia, individually and collectively rcferred to herein as Assigncc or Assignecs,their successorsend assigns, all of thc Assignor's rightr, title and interest in and to any and all commissions and other compensation of any nature whatsoever now due and payable or hereaftcr to bc€ome due and payable under the terms of any and all agencycontracts and commission agrccmcnrs, now or hcreafter existing, bctwcen thc Assignor and each Assignee, This Assignmcnt is given to securethc payment of any presertt or future debit balancein the Assignor's account with cach Assignee and any othcr prcsent or future indebtednessof thc Assitnor to each Assignee.Notwithstanding anything to the conEary i! any othcr agreement heretofore or hercafter cxccutcd betwecn the Asignor and any Asigace, it is expressly ageed, but lot by way of limitatioo, that the foregoing includcs repayment of advancesagainst commissions heretofore or hereafter giveo to the Ascignor by any Assigneetoward repaymcnt of such advancesand iqterest, This Assignment shall be subiect without exception to thc tcrms, limitatioos and conditions of said ageocycrntracs aad commission agreements and to all rights thereunder of thc Assignccs, their successorsand assigns. Notwidrstanding this Assignment tbere is rcscrvcd to cach Assignee,is successorsand assigns,the right to offret against said commissions aad other compeosation any and all advancesfrom dre Assigneesto thc Assignor and any indebtednesswithout cxception ofthc Assignor to aoy Assigneenow existing and such other and futurc indebtedriesswhich any Assigncc, its succ€ssorsand assigns,would have beenauthorized to dcduct ftom or of6et against said commissions or othcr compensation payablc to thc Assignor if this Assignmcnt had not bc€n madc, If the Assignor is or hercaftcr becomesinsured under or covered by any group insurance, pension,retiremeng defcrred compensationor other bencfits plan, or any policy plan providing errors and omissions protectioa or simi.lar insurance, provided by any Assigaeefor its agents o! utilizing any Assignee'saccounting facilitics, thc Assignor reservesthe right to authorize any Assignc€,or to continue any existing authorization, to deduct from ssid commissions and othe! compensation the Assignorb premium or other coutdbutions to or for suchplans and policies and to authorizc incrcascs in thc amount of such dcductions. It is the intent of this Assignmcnt that aay Assignce rcceive and retain the commissions and other compensation which are the subiect of this Assignment only to tie extent neccssaryto seculereFryment ofany present or futurc dcbit balancein the Assigootb account with such Assigneeand aay o&er prcscnt or fufure indebtednessof 6e Assignor to etrh Assignce.Thcrcbrg notwithstatding anything to thc contrary herein, cach Assignceis hereby authorized and directed to pay all commissiqns and other compcnsation in thc Assignor's account witb such Assigncc to the Assignor for his/her own usc and pu:rposeunlessaod qtil an Assigncc dctermines that it is necessaryto cnforcc thc termc of this Assignment to plotect its inierect itr sucb debit balancesaud ottrer indebtedncsswithin the intent of this Assignment. Each Assigneeir hereby authorized and directed to pay all comrnissionsand otler compeusation helcby assigneddirectly to any other Assignee, unless aod until ir receivesa written releeseof this Assignment. All Assigneesare hereby authorizcd to lcceive any moneys now due aud payable and which may becomc due and payable uader the above indicatcd agencycontracts and cosurission agrccmcnts. The Assignor hcrcby ratifies any acts that any Assigneemay 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 executed separateassignpeats ia favor of each of rhc companies that consdtutc er Assigneehsreunder.

TOA56&1105

P.gc 5 of 8

Under currcnt tax laws, you arc required to give us your corrcct TIN (either a Social Security Number (SSN) or Employer Identification Number (EIN). The lnternal RevenueServices(IRS) usesthe TIN for identification purpoeesand to hclp verify the accuracy of your tax rcturn. You must provide your TIN whcth€r or trot you arc lcquLed to filc a tax rcturn. Transamerica must gcncrally withhold 31ol" of your commission payments if you do not givc us a correct TIN. Certain pcnalties 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 Security Administlation, pleaseeotet you! fust name, the last name shown on your social security card and your new last name.

.

Sole Propri€to(s: You (the owDer) must provide your individual aame al it appea$ on your social security card. You may also provide your "doing businessas" narne. You may use eithcr your SSN or EIN. Show the name that appcars oa your social securiry card and the busincssname as it was used to apply for your EIN or Form SS-4. Pleasenote rhat usc of aa EIN may result in unnecessaryIRS noticcs being 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 licensc O Copy of nou-resident Ucense(s) tl Supporting docunentation, i.c., court records ,l Voidcd check or savingsdeposit slip for Auto-Pay

TOA556-1I05

Pagc 6 of 8

Pare informacion en esp6tol, nisi? unttro.ftc.goulaedit o esaibe a Ia FTC Con*mu Room 730-A 600 PennsyhtaniaAae. N.W,, Washington, D,C. 20580 6 5.-'-'sy

ResponseCetrt4

of Your Rights Under the Fair Credit Reponing Act

The federal of Your Rights Under the Fair Credit Reporting Act (FCRA) promotes the accuracy,faimess, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting ag€ncies,including credit bureaus and specialty agencies(such as agenciesthat sell information about check writing histories, medical records, and rental history records), Here is a summary of your maior rights under the FCR.A- For more infonnatiou, includiag iaformation about additional rights, go to www.ftc.gov/ credit or write to: ConsumerResponseCenter, Room 130-AoFederalTrade Commission, 500 PeonsylvaniaAve. N.W., Washington,D,C. 20580. .

You must be told if hformation in your file has becn used againstyou. Anyone who usesa credit report or another type of consumerrepon to &ny your application for credit, insurance, or employment- or to take another adverse action against - you must tell you, and must give you the name, address,and phone nurnber of the agencythat provided the information.

r

You have the rigbt to know what is in your file. You may requestand obtain alt the information about you in the files of a consumerreporting agency(your 'file disclosure"). You will be required to provide proper identification, which may include your Social Security number. ln many cases,the disclosure will be frec. You are entitled to a free file disclosure if; r . r a .

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

In addition, by Scptember2005 all consumers will be entitled to one free disclosure every 72 months upon request from each nationwide credit bureau and ftom nationwide specialty consumer reporting agencies. See www.ftc.govlcredit for additional information. o

You have thc right to ask for a credit score Credit scoresare numerical sunnraries of your credit-worthinessbasedon information from credit bureaus. You may request a credit score from consumerreportirg agenciesflat create scorcsor distributc scoresusedin rcsidential real property loans, but you will have to pay for it, ln some nortgag€ transactions, you will receive credit score information for &ee from the mortgage lender-

.

You have the right to dispute inconplete or inacclratc information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumerreporting agency,the ag€ncymust investigate unlessyour dispute is frivolous. Secwww.ftc.gov/credir for an cxplanation of dispute procedures.

a

Consumer r€porting agenciesmust conect or delete inaccurat€, incomplet€, or unverifiable information, lnaccurate, incomplete or unverifiable iaformation must be removed or corrected, usually within 30 days. However, a consuner reporting agencymay continue to report information it has verified as accurate.

r

Consumer reporting ageEciesmry not report outdatd negative information. In most cases,a consumer reporting agencymay not report negative information that is more than sevcn years old, or bankruptcies

TOA 556-1105

Page 7 of 8

Accessto your file is limited. A consumer reporting agencymay provide information about you only to people with a valid need-- usually to consider an application with a creditor, insureq employer,landlord, or other business. The FCRA specifiestlose with a valid need for access. You must give your consentfor feports to be provided to employers. A consumer reporting agencymay not give out information about you to your employer, or a potential employeq without your wxitten consent given to the employer, Written consent generally is not required in the tucking industry. For more information, go to www.ftc,gov/credit. You may linit 'lnescreened' offers of credit and insurance you get based oo information in your credit rePort Unsolcited "prescreened" offers for credit and insurance must include a toll-ftee phone number you cal call if you choose to rcmove your name and ad&ess from the lists theseoffers are basedon. You may opt-out with the nationwide credit bureausat 1-888-OPTOUT(1-888-567-8d88). You may seekdamagesfroE violators. If a consumerreponing agency,og in somecases,a userof consumer reports or a furnisher of information to a cotrsumerreporting agencyviolates the FCRd you may be able to sue in state or federal court. r

Identify theft victims arrd active duty ofitary personnelhave additional rights. For more information, visit www.ftc-gov/credit.

Statesmay enforcethe FCRA, and many stateshave thcir own consumerreporting laws. In somecases,you Eray have more rights under state law. For more information, contact your stat€ or local consumerproteclion agency or your state Attomey General, Fedcral enforcers are:

TYPE OF BUSINESS:

CONTACT:

Coasuoer rcporting agcocies, crcditore and others oot listed below.

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

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

Office of the Comptrollcr of the Currenry Compliancc Manageoeut, Mail Stop 6-6 !0ashingon, DC 20219

800-673-6743

Fcderal Rcserve Eoard Division of ConsuEcr 6c Comnudty W.shingtor! DC 20551

202452-3693

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

banks,

SaviDgs associations ard fuerally chaneredsaviugsbalks (wod "Fcderal"or initiale "F.S.B,"appearin ledcralinstitution'strema Federal credit unions (words 'Fedcral Crcdit Uniol. institution's nemcl

appcar in

A-ffairs

Office of Thrift Supervision ConsumerCooplaino Washington,DC 20552

800-842-6929

National Credit Union Administradon 1775 Dukr SEcet Alcxandria, VA 22314

703-519-4600

State-chancrcd banks thar are not mcrabcrs of rhe Fedcral ReserveSystcm

Fcderal Dcposit lnsurancc Corporation Corrsurn.r RcslroDscCcntcq 2345 Grand Aveoue, Suitc 100 Kansascty,Missouri6410S-2638 7-877-275-3342

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

Departrncnt of Transponadon, Office of Financial Managcmcnt Ve8hington, DC 20590 202-366-1306

Activities subicct to thc Packers aod Stockyald6 Act, 1921

Dcpartment of Agriculture Officc of Deptty Admin;tator Vashington DC20250

TOA 558-1105

Pagc8 of 8

- GIPSA 2O2-7ZO-7OSL

D Tr.rsrm.ricr

|,.,'..,

Eo

Occidcntal Life Iniurenc. Corlpary

Erraasamcricalirckrsurancecompanv

E IRANSAMERICA

INSUMNCE & INVESTMENTGROUP

Auto-Pay

Authorization

C€darR;i&, tA 52499

GAName:

Of6ce ID,-

This secrioo euthorizes Tralrsacrerica Occidental Life Insurance Compaay/Tmacamerica life Iosurance Gompany to deposit your bi-weekly commissionsinto your drecking, money market or savingsaccount- For a checkiug or uoney market account, pleaseinclude a voidcd check or deposit slip. For a savingsaccoung pleaseindudc a deposit slip. I herebyauthorizc TransamericaOccidental Life Insurance Company/Iransamerica Life Insurance Company (hereafter callcd the Company) to initiarc dcposits (crcdits) and./or irnmcdiate/sameday corrections to dcposits, iI proccsscdin crrog to the fiaaocial institution indicated below. Tbe fioaocial institution is authorized to credit and/or correcr the a&ounts to my account, This autbority is to remain in full force and effect until the Coupany has rcceived writtcn notification ftom mc of its teruhation in such timc and such manner as to afford thc Company and Financial lastitituion a reasonableoppomrniry to act on it. Note: The CompaDy will not utilize thiE authorization to collcct outstanding balanccsowed to the Company. Alternative rep4yneot methods must be established benveen you and the Company in accordancewith the terms of our contrac,tual agreement Your NaEe:

Your AgeutID:

Social Security Numben Prderred Addrers: City Prefcrred Phonc #

St tc

Zip Code

Starc

Zp Cade

E-mail Addrcss:

Fbaocial Institution Name: Fbarcial Institution Address: Streei Che&ing

City

or Savbgs Account Nuober:

Account Types: E Chccking/Money Market

EFT Traasit/ABA

Numbec

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 sigoht ofFccr of dte account (iI a corporarion/frm) is rcquircd. tt Accounrboldcr's Signarurc

TOA5s&208

(If signing officer of corporation/firm)

Datc

rflil]llltrililr||l[l rDc54r

II€]'LIFE tN!'ESTORS DIRECT DEPOSI'T FORM FOR COII\I ISSIONS

FAX {860}108-7?08 tlAlL ('()DE: t'l}]LD COIIPE\SATl()\ (16'r'tloor)

SEC'l'lOl\ | - AGI]"T INFORMA I'lO\ SocialSecurityNunrber ,. Phoue\unlber: {

_

OR lax lD \umber

)

.{eent Co||]ract Name (pbase pnnl)

( ontrLr(! r\ i ls. ! ontll el( Lt.lirnt.ltr' e.t. lt

\1 .( l l o \ l l , D tR t.c f D E P OSII I\t()R u,\ t-l ()\ Selcct services; f] .\utorurtic l)ircct l)cposil [ .tccount ( hrrrrgc \vherc palnrcntshouldbe disbursed The t)ine-digittransilnunlberand accourlnunrberis encodedatthebotlom r)f Enterthe accourr( or savirtgsaccounl!\ilhdra\\al sllp !!!Sf bc atlached1oensurethe correct nunrbersarc obtairred. )our check, .-\ cop) ofa l3)l!!8-.lql!!g5 The accountt)pe indicateswh!'therthe accountis a prinr:lry checkingor p tllary s||vings.

9000 'l ransit \umber

,.\ccountNnrnc

\ca()ut|t Nuniber

,\ccount Tr pe

Direct Deporit 9; ( \ l u s t b e 1 0 0 9o )

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SE( TION tll - ACETiT AtrTlrORIZAl'ION/,IGREEi\I E\T I . | he ! n d e l s i g n c d ' h e | e b \a u lh o | ilcII.r lI' ill| | l!cskn .s( ) n lt| | ca\ai |i tbl fD cl c(Jtl nni $j xn1Jan

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PLEASE Rf,TLRIi CONIPLETED ORRDVISED FORiIITO: \letl-ife lDrcstors, FicldConrpetrsatiol| (16'htloor), P.O.Bo\ 9900t?.Hartforrl,CT 06199-0011 (877)MET-0411prompt5 or Fax(860)J08-7708 FieldCornpenslrtion Form 330.1J(12105)

MetLifc I ndependentDistribution Profile Fornr \ ll. Il\lSA Statement (VlelLifelareconrnrilted The N4etlifeal'filiatedinsuranccconrpanies rvith the highesterhicaland ro conductingbusiness legalstandards.\'e havecstablislred atradrtionol integrit)indealin-r$irhourcustonlers\let[-ile hasadopl!'dthe eihical ma rke tofc onduc t pr ogr ar of t helr s uf anc e\ la r k e t p l a c e S t ! n d a r d s . \ s s o c i a t i o r 1 l l l S , , \ ) . , \ s d e s c r i b e d b e l o \ \ . \ l e l l i fe .a tl employees and distribrlorsarc c\peclcdb observelhe PrinciplesandCodeot ltlS-{: l. I -l. 1. j. 6.

lo conduclbLtsiness accordingto hish standards ofhoncsl) and lairnessnndlo rcndcrthal scrviccl() our customelsq hich. irrthe santccircurrstance. rverrould appl\ to or demalldlirr jlsclf. -lo provideconipeteut itndiuslt)nter-lbcused salcsand s!'1.\'ice. To engageill activeand laif courperition. -lo proride advertisirrg and salesmat€rialslhat ire clearas to purposeand lronestand lair as ro conl('nl. To pro\ide lbr fair and erpeditioushandlingofcusrourercorlplai ts and disputes. To maiDlaifla systenrofsupcrvisionand reviervthatis rcasonably rvith desigled1oachieveconrpliance thesepfinciplcsoferhicalnrarkerconduer.

VllIAckno\iledgemcnt:r||dAuthorizaiiotl Ih.'reb) cerlil-\thnt I h!\c rctd and unJclslarrrl thc itcmsor)lhis appoi|llncnllbrnrandthat nrr ans$ersare lrue and complele1o(hc bestof rny Inorr lcdge. I hare beenadviscdthat \letlife. lnc.. \lciropolitan.Ceneral,\nrcrican.\lalnul SlreelSecurilies. \letlife IIvcitors. and Ncu'linglandFinanciilardiheirnftlliatcs(hereafiefreferredtoas "l'he Conrpal)ies) Ilra\ conduc(iriv.stisatious ir ronncctronwirh nt) fequestto feprese0r 1he ( oIl]pa0icsin dte s0liairirionol producls.lauthorizeirn inquir)'tr)be nladeofall soufcesdecuredapproprialcb)'The Conlparries certaininsurance for tlre purposeofobtaininginfornlaliollconcenlirrn nrt trusiness pr'actices andethics.backgrouud. crcdithiston. and financial status.includin{,but not lillitcd to. nr! rccord.ifan}. on tjle \\itlr the FNR.{ CenlralRecordsDeposilory..\n) infomrationthat l-he Cofipaniesnr.r)obtairraboLrr me will be treatedascorrfldelltial and may be sharedrvith the appointirrg gerteralageDl.if nccessan'. I releasethe brokerdealerand (r' its agentsand an) persoDor clttitl , rvhichpror'idcinformation prrrsuant to lhis arrtho|ization. lionr anl and all liabilnics.claills or la$suitsin an\ nratterfelntedlo e inlb |ation oblainedfronrany and allofthc abole relirencedsourcesusedlo the exrentpernrittedby law. I undetstand lhat no right to corlrnrission or olherconrpensalion shallariseor exist until I ha\e beenappoillledand all due diligencesucccssiirll)approvcd, lf I anr apprlved.I shall acccpras full ron)pensation for all ser\,ices to bc perlbrnlrdh) prorideclin the iipplicableromurissi(rn nte.the colnpensalion nnd ;onrpensation scheduleas issucd.s bstitutcdor chaDge(l As an appornlcdagen!brokcr.I shirllobser\cltrd be bould bt tlrc rulcsand rcgulillionsof lhe Cornpanies. I a{reeto conduct \ businessi a.cordanceNith the l\lS.{ PriIciplcsot l:thical\larker ('o,lducr. CorDorate: Name lpleasepritri legiblv)

Signature

Date

\arle (ple as epr ir r lleLr bl\)

Sig JtLrrc

Da!e

ProlileFonn (3,r:007)

D/SCLOSURE By this document.[,4etLife Inc.and all affiliates(hereafterreferredto as "The Companies')discloseto you that a consumerreportor an rnvestigative consumerrepod containinginformationas to your character,general reputation,personalcharacteristics and mode of living. may be obtainedfor employmentpurposesandlor in connectionwith your applicationor request to representThe Companiesin the solicitation of certainproductsand services.A consumerreportor an investigative consumerreportmay be securedas paft of a pre- employmentand/orpre-appointment background investigation and at any time duringyouremployment and/orappointment.Shouldan investigative consumerreportbe requested.you will havethe rightto demanda completeand accuratedisclosure of the natureand scopeof the investigation requested.and a writtensummaryof your rightsur]derthe FairCreditReportingAct ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receiptof a separatedocumentsettingforththe abovedisclosureby MetLifeInc. and all affiliates(hereafterreferredto as 'The Companies) that a consumerreporl or an investigative consumerreportmay be obtainedby The Companiesfor employmentpurposesand/orin connection withyour application or requestto representThe Companiesin the solicitation of certainproductsand services.A consumerreportor an investigative consumerreportmay be securedas part of its preemploymentand/or pre-appointment backgroundinvestigationand at any time during nry employmentand/or appointment. I authorizethe procurementof such consumerrepofis by The Companresfor the purposesdisclosedto me. lf I am hired and/or appointed,or if I am already employedand/orappointed.this authorization will remainon file and will serve as an on-going authorization The Companaes to procuresuch consumerreportsat any time duringmy employment and/orapporntment. I herebyauthorizean inquiryto be madeof all sourcesdeemedappropriate by The Companiesfor the purposeof obiainingjnformationconcerningmy businesspracticesand ethics,background.credit history,and financialstatus.including,but not limitedto, my record.if any. on file with the FINRA CentralRecordsDepository.Any information that The Companiesmay obtainabout me will be treatedas confidentialand may be sharedwith the employees.agents,or generalagentsof The Comoanies. if necessarv Any copyof thisAuthorization shallhavethe sameauthorityas the original. tr

I would like to receivea copy of atry consunrerreport or investigativeconsumer reportreceivedby the Conlpanies.

h r r i n gl v l a n a g e isNa ' n e

Pflnled Narne of Applican!rEmpi.yec

!Mtness Sgnature

Prinled Name cf Vvitness R e f o r mA c l E m p lo ym € n URe g istr a tio n o su r e /Au horzal ton Dr sc

D/SCLOSURE 8y thisdocument,MetLifeInc and all affiliates(hereafterreferredto as "The Companies')disclosero you that a consumerreportor an investigative cor'rsumer reportcontaininginformation as to y our character.general reputatjon.personalcharacteristics and mode of living, may be obtainedfor employmentpLrrposgs and/or rn connectionwith your applicatron or requestto representThe Companiesin the solicitation of certainproductsand services.A consumerreporlor an investigative consumerreportmay be securedas part of a pre- employmentand/orpre-appotntment background lnvestagatron and at any time duringyour employmentand/orappointment.Shouldan investigative consumerreportbe requested,you will havethe rightto demanda cornpleteand accuratedisclosure of the natureand scopeof the investigation requested.and a writtensummaryof your rightsunderthe FairCreditReportingAct. ACKNOWLEDGMENT AN D AUTHORIZATION I acknowledgereceiptof a separatedocumentsettingforththe abovedisclosureby lvletLifeInc. and all affiliates(hereafterreferredto as The Companies) that a consumerreportor an investrgatrve consumerreportmay be obtainedby The Companiesfor employmentpurposesand/orin connection with your application or requestto representThe Companiesin the solicitation of certainproductsand servrces.A consumerreport0r an investigative consumerreportnray be securedas part of Its preemployment and/or pre-appointmentbackground investigation and at any time during my employmentand/orappointment.I authorizethe procurement of such consumerreportsby The Companiesfor the purposesdisclosedto me. lf I am hired and/or appointed.or if I am already employedand/orappointed,this authorization will remajnon file and will serve as an on-going authorization The Companiesto procuresuch consumerreportsat any time duringmy employment and/orappointment I herebyauthorizean inquiryto be madeof all sourcesdeemedappropriate by The Companiesfor the purposeof obtaininginformationconcerningmy businesspracticesand ethics,background.credrt history,and financialstatus includingbut not limitedto my record,if any, on lile with the FINRA CentralRecordsDepository. Any informationthat The Companiesmay obtain about me will be treatedas confidentialand may be sharedwith the employees.agents,or generalagents of The Companies. if necessary. Any copyof thisAuthorization shallhav ethe sameauthority as the original.

H r n n gl M a n a g e isNa m e

S i gnarure of A ppl i cant/E rnpl oyee

P rnl ed N ameof A ppl i canvE mpl oyee

Print€dName ol Wtness R e i o r mA c t E mp o yn r e n VRe g r str a lrDosc n o su r e /Au thori zaton

MLl. this Agtccnrcrrt shallbc gorcrnedbr thc larrsof th,,.Statcol Delarrarcrrithoutregardto Delauarechoiccof larrrules. Sectionl0.l"l. Jurisdicrion.\\ itlt rcspL"ct to an\ acrion.suitor otherproceeding benreen\ll-lC andBrokcr.cachofthc Particsirrevocablrandunconditionally subnritsto the non-cxclusive iurisdictionof tlie Lnit,,'dStatesDistrictCourtforrhe Sourlrern DistricrofNe\ \'ork or. if suclr coun sill not accepr.iurisdict ion. rheSuprcrlcCoun ofthc StateofNes, York or anl,coun ol competentcivil.!urisdiction sittingin Neu York County.Nel York. \\/ith respccrto an)-acrion. suitor otherproceedinlbetrveen i\4Ll and Broker.eachol the Partiesirrevocablland unconditionalllsubrnitsto tlrc non-cxclusivej urisdictiorrol'thL'LlnilcdStatcsDistrictCoun for theSoLlthern Districtol Dclatiateor. i1'such l ill not ircccpt.iurisdiction. cr.rult the Superior Court ofthe Stareof Delauareor an,\,counofconrpetent civil.jurisdiction sittingin Delaware.lnanv action.suitol otherprocecdint.eaclrol'the Partiesirre\ocabl\andr,rnconditionallr rraircs ancl agreesnot to asseftby \\a! of motion.asa defenscor olhenvisean; clait'l]sthat it is not subject to the.iurisdiction ofthc abovecourts.thatsuchactionor suit is broughtin an itrconvenient tbrunror thatthc \.enucofsuch acrion.suito[ otherproccedingis improper.Eaclrofthe ltanies herebyagreesthatany tinal andunappca lable.iudgrrentagainsta Partyin connectionwith antaction.suitor olherprocectling slrallbc tinal andbindingon suchPartrandthatsucha\ard or judgenrentmay be entbrcedin any courto,'comperent jurisdiction.eitherwithin or outsideofthe UnitedStates.A certiliedor cxcmplilicdcopvol sucha*ard or.judgment shallbeconclr.rsivc evidenceofthe l:rctandar'lloul'tt ofsuch auard or'.judgrrrent. Section10.15.l{orl \\'c Do Business GLridc.Brokeruckrrowledgcs thathc or shehasreccivccl Metlit'e's How We Do Business Guide.the ternrsof uhich are incorpomted hercinbl reltrcnce. andagreesto compll rr ith thc rulesandrequircnrcnrs sct forth in \lctLilt s Hou We Do Business Guide. METROPOI,ITANI,IFE INSURANCI COMPANY PrintNanreof Broker aI

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NIETLII.E INVISTORS USA INSLJRANCtT COMPANY

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