PLEASE NOTE: License papers must be submitted with your first application.

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1 PLEASE NOTE: License papers must be submitted with your first application. U.S. Life requires at least $1,000,000 of ERRORS and OMISSIONS insurance. Please attach proof of your current E&O coverage.

2 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) ( 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 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 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 Securities License Series q 6 q 7 q None Securities License Series q 6 q 7 q None SS#: DOB: SS#: DOB: 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 -

3 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, 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 )

4 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 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:

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