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Unity FinqnciolLife lnsuronceCompony PrivocyPolicyfor Agenls qnd Policyholders
PrivcrcyPolicy At Unity FinancialLife InsuranceCompany,we arecommiftedto safeguarding your privacyand keepingyour personalinformationsecure. We collectnonpublicpersonalfinancialandhealthinfornrationaboutyou from the following sources: .
lnformationwe receivefrom you on applicationsor otherforms
.
Infonnationaboutyour transactions with us,our affiliates,or others;and
o Informationwe receivefrom a consumer-reporting agency. We do not discloseany nonpublicpersonalfinancialor healthinformationaboutour customersor formercustomersto anyone,exceptaspermittedby law. We restrictaccessto nonpublicpersonalfinancialandhealthinfornrationaboutyou to thoseemployees andcompanyagentswho needto know that informationto provideproductsor servicesto you. We maintainphysical,electronicandproceduralsafeguards that complywith federalandstateregulations guard personal your to nonpublic financialandhealthinformation
COMPAT.IY UNITYFINANCIALLIFEINSURANCE
"unil}t
FORPRE+IEED GENERAL AGENTCOMTRACT APPLICATION
Pleaseattach a copy of J,our currenl license far eachstate iil x,hich1,sutt,ishto he appoinled.lf it is a Corpotationar paltnership eochafthe sublicenseer. pleaseprovidea copl,ofthe c'ontplete Pleaseanswerall queslions: licenseshrsv,ing regaestingappointment,
GENERAL AGENT: PROSPECNVE Male or Female
SSor TaxlD # Manuging GeneralAgenUAgency:
Date of Birth:
By your signaturebelow,you c€nirythst you haveprovidedyour corrccttaxpayeridentificationnumbcrandthatyou rrc not subjectto baclcrp
ADDRESSES both Residenceand Buslness
For policy issueor client servicequestions,pleasecontactmc by: _-**
Telephonc
Pleasesend my commissionsand relaled information to my: .--...-_ Resldence Subjectro specificslaterequirements,pleasescndpolicl, con(ractsto nry: --
State
Referoace#
--
_
Fax _
Intcrnet
_
An!'
Eusiness
Resldence -__
Euslness
STATE LICENSES TVpeofllcence
Lines of Buslnesr
Do you hold a current Funeral Director's License for the stale in which you intend to sell life insurance? Are you a U.S. Citizen? .*__Yes _-.- No
Yes
No
PASTFIVEYEARS EMPLOYMENT HISTORY Nrme of Company
ADDolntnetrt elfcctive datcs
Prodsc{ion
Fmm:
From:
To:
From:
To:
or a breachoftrust, to participatein Crirninal Historyr FederalLaw prohibiuanyonewho hasbeenconvictedof a felonyinvolvingdishonasty anyof thesublicensees) everbeenconvicledof any crlmc (includingDUI) otlrerlhana of insurance.Haveyou (or, if a corporation, thc business minor trafic oflense?If yes,pleaseprovidedetails,includingdate,jurisdiction.chargeandsentcnce._ Yes -_ No lf so,plcaseprovidename(s): Finnnciallnformrtion: llave you evcrusedanyothcrnarne(s)? corpany, its managers or maneginggeneralagents? Are you presentlyindebtedto any insurance No I'laveyou filed for hankruptcywithin thepastsevenyears?: *__ Yes
Date:
Signature:
Yes
No
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UNITY FINANCIAL LITE INSURANCECO}IPANY PO Box 625700 Cincinnati.OH 45262-5100
General Agent's Agreement BetweenUnity FinancialLife InsuranceCompany("the Company")and
l.
of
.dppointment. The Companyherebyappointsthe GeneralAgentto conductan insuranceagencyto solicit applicationsfor life insurance and annuities,both individualandgroup,to be submirtedto the Companyfor approvalor rejeclionandto collectandremit to the to deliverpolicieswhenthe termsandconditionsgovemingsucbdeliveryshallhavebeen Companythe first premiumson suchinsurance, compliedrvith, and to performsuchotherdutiesasmay be requiredby the Company.TheGeneralAgent shallhavethe right Loappoint agents,with the approvalof the Company,on the formsfurnishedby the Company,onecopybeing filed with the Company.The OeneralAgent shall be responsibleto the Companyfor all mattersentrustedto him andfor his actsand conductrclatingto thebusiness of the Company,andagreesto hold the companyharmlessftom andagainstany and all claimsof all agentsandpersonsemployedby him. Relationship.This agreementshallnot be construedto createthe relarionshipof employerandemployeebetweenthe GeneralAgcnt andthe Company.The GeneralAgent is herebyconstitutedandshall in all respectscontinueto be an independentcontractor.The CeneralAgentshallbe freeto exercisehis own judgmeltasto thepersonshe wi.llsolicilfor insurance. of theCompany, now or hereaftcr Rules.The CeneralAgentshallconfornrto all therulesandregulations to becomein force,rvhich shall constitutea part of this Agreement.
4"
Funds.The GeneralAgentshallimmediatelyremitto theCompanyall fundsreceivedor collectedon behalfof theCompany.
5.
The GeneralAgentshallhaveno poweror authorityto do anyof the follorving: a. b. c. d. e, f g.
joinl ventuteor officer of the Company. Representthathe is an employee,associate, Changeor waive anyof the terms,condilionsor ratessetforth in promotionalmaterials"or any advertisements, reccipts, conhacts,appiications,or policiesof the Companyin any mannerwhatsoever. Issue"prinl or circulateany advertisement, or salesmaterialconcerningthe Companyor any othercompanywithoutobtaining prior approvalin writing from the Company. Bind the Companyon any applicationfor a policy of insuranceor groupcertificate. Extendthe time of payingany premium,or rebateor offer to rebateany pan of a premium. or incompletecomparisonin orderlo inducepolicyholdersof the Companyor any othercompany Make any misrepresentation to convert,lapse,surrenderor forfeit his insurance. Exerciseany authorityon behalfof the GeneralAgentor the Companyotherlhanthat expresslyconferredby this Agreement unlessauthorizedby the Companyin writing.
The Companyshallhavethe rightto seloffany debtsowedb1,theGeneralAgentto theCompanyagainstany Indebtedness. dueor which may becomeduethe GeneralAgent.ln additionto suchright of offset,the GcneralAgentrvill payon compensation demandany amountsowedto the Companyduringor aflerthe life of this confract,includingany collectioncostsincunedby the Company, Sub-Agont Indebtedness.lfthe OerreralAgent hasSub-Agentsfor which the GeneralAgentreceivesan ovenidecomrnission,the incunedby suchSub-Agents.The GeneralAgenl will thepaymentof any debit balanceor otherindebtedness GeneralAgent guarantees pay the Companyon demandif the Company,in itsjudgment,is unableto collectsuchbalanceswhen due.lf tlreGeneralAgentpays the Companywill assignits rightsto suchindchtcdness to the GeneralAgent to theextent the Companyfor a Sub-Agent'sindebtedness, of the GeneralAgent'spaymentsto the Company. 8. Legal Proceedings.The GeneralAgent shallhaveno authorityto institute,prosecuteor maintainany legalproceedingsin connection with any matterpertainingto the CeneralAgent'sor Company'sbusiness,exceptwith lhe written consentof the Company.In the event any legalprocessor lotiee is servedon the GeneralAgentin a suit or proceedingagainstOreCompany,the GeneralAgent shall forthwith forwardsuchprocessor noticelo the Companyby ovemightdelivery. 9. Changeor Termination. This agrcementmay be changedfrom time to time by writtennoticefrom the Companybut no suchchange shallaffect commissionson any contractor policl issuedprior to the effectivedateof thecharge.Eitherparty may terminatethis Agr€ementat anytime by giving the otherparty ten days'noticein writing. This Agreementshallterminatefoilhwith on the deathof the dueto or indebtedness owedby the GeneralAgent at his deathor falling due therea&er,underthis GeneralAgent.Any compensation Agreementshallbe paid to or by his executorsor administrators.
l0' Termination for causc' If theGeneralAgent6hallwillfully or knowingly I submitany falseinfornration,or (2) concealanymaterial { ) fac(sconcemingthemedicalor personal history.ofany applicantor prop'o"r.a insured,ori3; .o*^iir*uo, or (4) withholdor convenro his own usemoneyor documenlsbelorlgingto theCompany,or (5) iewriteor causeto berewritten with anyoirr", in*r", *y porirv in forcewith the company,whetberor nolsuchpolicy hadbeenwritrcnby theGeneralAgent, withoutprior writtennoricero the company,or (6) induceor attemptto induce,any oeneralAgenlor rrnptoyo ofrhe co:mpaoyto ieale ib serviceor ro ceasesoliciting or writing business for lhe Companyor to decrease thevotumeof businessl so written,or (f rmpropertyinduce,gr attemFtto induce, anypolicyholderof thecompanylo discontinue premiumpaymenbon rbispolicy,oi (s) tblr ro conrormlo therulesand regulations of thecompany,or (9) fail to cornplywith the larvs,and reguiations of anystate rhe6eneralAgentis appointedby thecompany.or 1!ire fail to maintainin goodstandinghis license(o sell insurancein suchstatesor ( l0) violateany orttie provisionsor conditionsof this Agrecment,theCompanyshallterminatethisAgreemenlby rvrittennoticeandall interest tueceneralAgentmayhavein a'y commissions andany othercompensadon underthis andpieviousagreemenrs madewith rheCompanyor anyof its agentsshallbe forfcited'such terminationdoesnot relievetheCeneralAgentof arr! obligationsto pay indcbtcdness owedatrhe time of terminationor thereafter. I | ' Commlsslons'As compensalioD for hispersonalproduc{ionandhis servicesasGeneralAgent,lbeCeneralAgent shallbe paidby ttre companycommissions computedin accordance with-theaccompanying cbnrnrissionschedutes. Thecommission schedules shallbe subjecrto changeby the Conrpanyat any time,suchchanges to 6eappl;abteto all policiesissuedaftertheeflectivedatethereof. commissionsarenot camedon policieswhich are l:tumed to thecompanyandvoided.Theconrpanywill recoveran amounlequalto thecommissions paidor advanced on anypolicy which,duringits firstpolicyyear,was l) surrendered for the policycashvalueor z) for multipayplans,lapsedfor nonpalnrentof premiumsdue.lf thi insurediiesprior to thefiist poticy annio"naryfiom olherlhan accidental death'thecommissionwill bechargedback 100%duringtbefirsisix monthsnom nr Lsuedate. Alier thepoticybasbeenin forcet 82 days,fre chargeback witl beproratedon a monthlybasisfor thc remainder of thcyear.If we void or rcscinda policy dueto contesting a clairnon a dealhthecomrnissions will be charged back100% l?' Renewalcommisslons' If anypolicywrittenunderthis Agrremenrshallceoseto be in forceon a prenrium-paying basisfor a pedodof ninetydays,fiom theduedateof thepremiumin defaultanJbeeubseguenrty reinstated, ti,. oen"ruiagent shallnot be entitledto any furlherrerewalcommissions on suchpolicy unlessthepolicy is reinstated throughhis agency. l-3' commissionPaymentsand Refunds.No commissions shallbepayable on anyrejected application.shoulda policyissuedonan applicationsecured by the GeneralAgcntlapseandnot be reinstated, theGeneralngenrshailhavens furrherintercstofany kind in the policyunlessit bereinslatedthroughtheeffortsof his agencywhile ihis agreement is in effect.shouldthecompany,"n oi,-r,. p."*iufor anyreason,includingbut not limiledio cancetlalioninclrescission, oii{ policy writtenon an applicationsecuredby theAgenl he sballrefundto theCompany,if so instructed, any andall moniesreceived by him by Lasonorrrtr pril*nt of suchpremiums. 14' Reportingof subsequentEvents.After thedateof this contractGeneralAgenrshallpromprly notiry companyif theGeneralAgentis arrestedfor or convictedof anymisdemeanor or felonyotherthanminortrafrc violationsoi iicenriir aedr rlrasror uant^f"v', ,itr,", pcrsonallyor for anyentitvdircctlyrclatedto his or her insurance business. l'5 Limitations' Theoompanyresewestherigbt,in its solediscretionandwithoulliability to lhe GeneralAgent,to disapprove any applicalionfor insurance submittedto it by theGeneralAgentor snyagentor personunier his supervision andto limit or restrictthe amountof or planof innrranceit shallissueandto requiri a higheipremiumlhat lhanapplied for. 16' Assignment'ThisAgreemcntis not transferable' No rightsor intereslsunderthisAgreemenlshallbe subjeclto assignment withoutthe wrillenconscntof theGencralAgentaudthe Company. | 7' Waiver' Thefailureof thecompanyto enforceanyprovisionof thisAgreement.or to insistuponsrrictcompliance by theGeneralAgenr with 8nyof theprovisionsshallnotconslitutea waivir of anyof therighisorprivileges 6"rpriry underrhisAgreement andshall not bedeemedto constifutea courseofconductor waiverai to anysribscguent acts. "itrt. l8' Entlre Agreement'This Agreementshatlsupersede anyprior Agreement befweenthecompanyandtheGenenlAgantin retationto policiesissuedthroughtheGeneralAgenlaftertheAgreernent bJcomeseffective.fie foregoing.rogeiherwith accornpanying schedules, constitulestheentireAgreernenl betweentheparties. 19 Liabiliry'Eachshareholderorpannet!iftheoeneral Agentisacorporationorparhership,personallyandfullyguaranteeslhe performance by theGeneralAgcntof everycommitmcnt,covenant andundertuking in rlis rqlr"em*i, p.-ia"j ,irr1,p"oun u, p.oon, hassignedthiscontractindividual|yoronbehalfoftheGeneralAgent|,''|oi^,'..)|l.>
tt*"[:t"xeo$i*9' t;n'i'e Sunervislng GeneralAgent(s)
Gcncral Agcnt
DELCO ManagingGeleral Agcnt
Datc For the Compeuy
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UNTTY FINANCIAL LIFEINSURAN-CE COMPANV PoBox6?5?00 Cincinnati, OH 45262-5?00
IINANCIAI-
Agreementfor ReserveAccount I herebyagreethat Unity FinancialLife Insurance Cornpany("theCornpan.v") reservesumsagainsicommissions to be eamedunderthe provisions andI ogreethat: of my GeneralAgent'sAgreenrent, paidaresubjectto polenlialchargebacks. 1. All conmissions I understand thalanyindebtedness remaining on thedatemy General Agent's terminates will beconre Agreernenl immediately payablein li:ll. Any indebtedness thatis incunedaflertermination of my Agreernent will be payableon demand. ?. RcserveFund: I understand thata Reserve Fundwill becreated, whereina percentage of my commissions will beheldat theCompany unlil a caohasbeenreached. lnitial ReserveFund Fercentage: Initial RcserveFund Cap:
rc% $3.000.00
Company Approval: Company Approval:
%
$
3,
Commissioncharge-backs will be withdrawn fiom thc ReserveFund fiat. lf the ReserveFund is insufficicnt,charge-backs will be taken fiom my next commission check. I understandand agreethat the ReserveFund percentagearrd/orcap amount may be changedat any time by the Company.
4.
This Agreementmay be lerminatedal any time for any reasonwithout notice to me.
Date:
Signed: _
Printfull nanre:
Authorizntion Signaturcs SupcrvisingCcncral Agcnt: DELCO
Datel
DELCO
Dale:
Chief N{arketineOffi cer:
Date:
MCA:
tt,.
Er
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UNrrY FINANTCIALLITE INSURANffi COXGAI{Y
F]NANCi/,1.
Candidate Notification Through this documentit is disclosedto you that an investigativeconsurnerreport will be obtained from a consumerreporting aiency for tle pqpose of evaluating you for agent appointmengemplopnenf promotion, reassignnentor retenfion as au employee or for eligibility for a license reguired by law to consider an applicant's financial responsibility. This report may contain infomation bearing oD yonr credit wor&iness, credit standing, credit crrpacrty,character, general reputatiorqpersonalcharackistics, or mode of living fr,ompublic rccord sources or tbmugh personalinterviews with your neighbors, ftieads or associates. You may also have a right to requestadditional disclosr:res the ndre and scopeof trre investigation
UNi.t^\l UNITY NNANCIAL l ,I N A N
LIF'E INSURANCE COMPANY
OH 4526? POBox 625700Cincinnati'
ound lnv
Authorizatio@
ations
schoolopolice department,financial I hereby authorizeand requestany presentor fornrer employer, me, to furnish bearerwith any and all institutionor otherp"rrorn having personalknowledgeabout lne in connection with my application-for agent iegarding -I information in tr,eir possession* of this authorizationbe accepted appointme't, employmentor license. am iuittiog that a photocopy any written authorizedrequest' I with the sameauthorityas the original, and I spicificalfy waive agent appointmentand/or employrnent understandthis authorlzationis to be part of the written applicationwhich I sign. a reportwill be requestedand usedfor the I have beengiven a standalone,consunrernotificationthat or retentionas oieiatuatin! me for ernployment,agentappointment,promotion,reassignment ;G"; financialresponsibility' an employeeor fbr ujir.nr* r.qrrit.d by law to conliO"ran applicant's
PrintName Signature Dateof Birth (for identificationpurposesonly) SocialSecuritYNumber (for identificationpurposesonly) If namechanged, (throughmarriageof otherwise) print fonner namehere
Date
h{n.ir}J DIRECT DEPO$IT OF COMMI$$ION$ AUTHORIZATION AGREBMENT FORM FOR DIRECT DEPOSIT OF COMMISSIONS I hereby authorize Unity Financial Life InsuranceCompanyto initiate credit entries and, if nccessary,debit enhies and adjustmentsfor any credil entriesin error to my account"I will not hold the banksliable for any erroneousdepositsor adustments. Flrst
Namc: l,ast (PleasePrint Clearly)
Address
Cit!'
State
Zlp Code
Agent Number (s)
ir1'6-A-ffiffXffimdriffifti
Date
Agent Signature
Pleasereturtr this to Unity Financialby: Fax: 513-247-5040or Email:
[email protected] OFFICE USEONLY: Entry Code:$!UFA
PRENOTE
DATE
Want24/7 $ccessto yoar account informstion? Sisn br YiLink todav!
Vilink:
Unity Financial'sAgent InformationSystem
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e-mailaddress:
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Retum to: Agent Services Unity FinancialLife lnsuranceCompany PO BOX 625700 CincinnatiOhio 45262-5700 Fax: 513-247-5040 When your requesthas been processed,you will be nolitiedby fax or emailwith all of the informationyou need to accessthe ViLink Agent System. Home O6ca Uee Only
Co.
AgentNumber(s)
States Licensed:
Praneed
ApproverJ by
Agency Number
(only if GA Access is Required)
_._.__
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UNITY FINANCIAL LIFE INSURANCECOMPANY PO Box 625700Cincinnati,Ohio 45262
ASSIGNMENTOF COMMISSIONS . hereincalled"ASSIGNOR"herebyassign,transferandset "ASSICNEE"all my right.title and interestin andto all called over lo . herenfter comrnissionsand any othercompensation now due andhereafterto becomedue on all insurancepolicies,presentand futurc, heretoforeand hereafterissuedby Unity FinancialLife InsuranceCompany(hereinaftercalled"COMPANY") procuredby me or in connection with any of my agcncycontracts with the COMPANY andall amendments. additionsor enteredinto by rnewith the COMPANY. supplements heretoandall new agencycontracts For valuableconsideration. I
ASSICNEE'SADDRESS: ASSICNEE'STAXPAYER ID NTJMBER: andothercompensation The COMPANY is herebyauthorizedanddirectedto paythe cornmissions forthwith,asthey shallconstitute a fulldischargeof the may becomedue directlyto the ASSIGNEEandthc rccciplof the assignee COMPANY on accountof saidpayments. thattheywill be responsible for any financialobligations thatresultfrom business TheASSIGNEEacknowledges sold pursuant areassigned to ftis agreement. for which commissions executed by the ASSIGNORrclevanlto theCOIT4PANY priorto this supercedes any andall assignments This agreement date.
SIGNATURES
ASSIGNOR: ASSIGhIEE:
Unity FinancialLife InsuranceCompany,by its Ofricer,
*' W-g
Requestfor TaxpaS'er fdentificaiionNumberand Cedlfica'tion
Giue form to thc requester. Do noi send to the lRS.
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Rrpose of Form A peaon wfio b equired to file an infqrndion rd,rn with tfte lFS, nugt obbln yotrr careci taQa'€r idedficdon nu.nber hcone pad to yal real esGle Gf.$to lepst lor eJ<arnpl€! t:anctocs, mdtgage hcrestyut peb, acqd$on or abardqrnert of Eecur€d prpperty,capelldicn cf debt, or corftihrfom you rnade b an BA LJ.S.pcrson Usa Form W4 otdy if pu are a U,S. person @duetg e recident alien).to povHe )eur consct TIN to ihe personrcques{ng ft $te requestedand, ufien applicable,to: 'IlN you ae giving b conwt for you are 1. Oerlirythat the unttirq br a numbq to bB breq, 2. Cerdtythat you are not sut'iect to backup withholding. or 3. Chlm er<emptionfrom beclrupwltfrholdirg if you are a US. elon$ payee. In 3 dorrc. il applicable, you are also certifying that as a U.S. person,your allocabte shareof any parbersftp inclme frun a U.S. fade or business b not subiec{ lo the wtthhoUng Ex on foreigrnpaffrers'share of ef{ectively corrr€cbd income. Nots lf a requester gives you a forro other &an Form Vrt-9lo requestyour TlN, you must us he requeter's iorm if it is sr.ffi,ly simllar 1o this For,n W-9. Forlederaltex porposes, you are considereda person if 1,su are
r An irdvidrral wfto b a citizen or rssilent d $e Ur&ed Slat€s, 3 A psrtstBrshh,corpoEfo.\ cofipaq/, d'Riaion creed or organized h Sp Llnitsd $dss or uderthe hws of tfe LjnibdMeg, or . Any cstaio (otherthzn a foreigrnes@) tr trust. See ReguHiom sedJotts 30i.7701€(al and ils) 6raddlfonal fflhrrdbn. SF€cbl rules for padnexttips- Parbershhs thatsrtrl a trade or brJsiress h tF tnlted $a!es ara gene:atty 7eqlft€d to pay a wiffrtptsing tax on any foidgn partrers' $ae cil inconp from sci hlshess. Fudher, in certaln cases wtpre a Form f4,€ has na't been reshted, a pailnechfp is reqlbeC to Fresume that I parh€r b e irreign pereon, and pay $e wltrholding tex- Tfpreforq ii you are a U.S- persan ttrat ls a parfter kr I p€rtersftip cmdudirq a tsadeg bJF.*ressin the United States, provlJe Fonn W'9 to llre paftensh'rp to estabfrshyour U.S- stalus anCavcfd withfrolding on you shareof parlnershipincome. The person wtro gives Form W-9 to he partrrership f* purposes of esbblis-hirg f's U-S. sbtus ard a\rddinq wlthholdirg on its allocableshare of net inoqre fttrn trre partrrerslip conductirg e tede or busins in ttre Untbd S,aEs b In the follouirg cases: r The U.S. oyrner of a disegarded wlity and not ths er[it],,
Ce(. No. 10?31X
Foci
W-toRv. ll-ittcs)
UNITY FINANCIAL LIFE INSURANCE COMPANY Cincinnati.Ohio PRODUCER'SCOMMISSION SCHEDULE The Producershallbe entitledto receivecommissionat the ratesshownon this schedulefor Groupor Individualproductswith applicationsor enrollmentformsdatedon or afterMay 1, 2008until furthernotice. Paymentof commissionunderthis scheduleshallbe subjectto all the provisionsof the GencralAgent's Agreementbetweenthe Companyandthe GeneralAgent and is subjectto changeasprovidedin theGeneralAgcnt'sAgreement.
SinglePremium Commissionsexpressedas a percentageqf nremi unt.
CIient IssueAge l-65 66-70 1t-75 76-U0 8l-85 86-90
9 r-99
Rate l5 I3.5 I 1.5 8.5
4.0 3.0 0.5
Commission Chargebacks: o o
o
Commissionsare not carnedon policieswhich are returncdto thc Company and voided. Thc Company will recoveran amount equal to the commissionspaid or advancedon any policy which, during its first policy year was surrcnderedfor the policy cash valuc. If the insured dies prior to thc first policy anniversaryfrom other than accidental death,thc commission will be chargedback 100% during the first six months from the issue date. After the policy has been in force six months, the chargebackwill be prorated on a monthly basis for thc rcmainder of the year.
I huve read and agree with the above: Signature: Print FullName:
Level 7T
Date: