Fill - Free fillable AUTHORIZED REPRESENTATIVE AGREEMENT This agreement is entered by PDF form

1 cont rev 9-14 f

Universal Life Insurance Company

PO Box 2145 San Juan Puerto Rico 00922-2145

T: (787) 706-7337 F: (787) 625-7300 www.miuniversalpr.com

AUTHORIZED REPRESENTATIVE AGREEMENT

This agreement is entered by and between Universal Life Insurance Company

(hereinafter the Company) and ____________________________________ (hereinafter the

Authorized Representative) and in consideration of the mutual promises, terms and conditions

set forth herein below, the parties agree as follows:

I. Authority of authorized representative:

___________________________________ is hereby designated as a limited non

exclusive authorized representative of the Company, as defined by and subject to the

provisions of chapter 9th of the insurance code of Puerto Rico, and as an independent

contractor, subject to all the requirements imposed by applicable federal and state law, the

terms of this agreement, the underwriting guides and rules of the company, and the

commissions schedule attached to and forming part of this contract, shall and/or may perform

as follows:

1. Shall solicit, receive and transmit to the company proposals for insurance contracts,

excluding fidelity and surety bonds, in accordance with the underwriting guides,

schedule and rules of the company and for which a commission is specified in the

attached schedule, both which may be from time to time changed by the company at its

sole discretion.

2. Shall provide to all insured’s, in conformance with the provisions of article 9.022 of

the Insurance Code of Puerto Rico, orientation in regard to the coverage afforded

under the insurance policies.

3. Shall collect premiums in strict compliance with rule xxix issued by the insurance

commissioners’ office. The authorized representative agrees to refund/return

commissions on policy cancellations or reductions in policy premiums collected.

4. Exercise his/her authority in compliance with all applicable labor and employment law,

personally or through his/her authorized employees

5. May represent, provide services and conduct business with other companies.

6. Shall exercise exclusive and independent control and discretion of his time and the

conduct of his business. Nothing contained in this agreement shall be construed to

create an employer-employee relationship between the authorized representative and

the Company.

The authorized representative does not have the authority and affirms that will not

perform, among others, the following acts on behalf of the company:

a. make, alter or discharge contracts;

b. incurs any indebtedness or liability;

HP AGENCY

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c. waives forfeitures;

d. extend the time for payment of any premium;

e. withholds any of the Company monies or property;

f. rebate premiums;

g. open bank accounts in our name;

h. endorses or deposit checks made payable to the Company.

i. any act prohibited by law

j. any act not expressly authorized in this contract / agreement

Section II. Ownership of expirations:

In the event of termination of this agreement, the authorized representative having

promptly accounted for and paid over premiums for which he may be liable, the

authorized representative's records, use and control of expirations shall remain the

property of the authorized representative and be left in his/her undisputed possession.

Section III. Changes in contract/agreement

The agent and the company each agree that all changes or amendments to the

agreement hall be executed in writing.

Section IV. Authorized representative's compensation:

The commission rates for a particular line or class of business, as specified in the

company's commission schedule with the authorized representative may be changed by

the company.

Section V. Contract duration and Termination of agreement

Either party to this agreement may, at its option, terminate this agreement with a prior

written notification of thirty (30) days.

Notwithstanding the aforementioned, the company may, immediately and without written

notification terminate this agreement before its expiration date, among other, for one or

more of the following reasons:

1. violation of the underwriting guides and rules of the company or any of the terms

of this agreement,

2. failure to pay accounts as agreed,

3. plead guilty, nolo contendere, or been convicted of a felony, including but not

limited to crimes involving dishonesty, breach of trust or a violation of any federal

or state law.

4. revocation of authorized representative's license,

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Section VI. Change of ownership and/or control:

This contract is only transferable at the discretion of the company and with its prior written

consent.

Section VII. Hold harmless agreement:

The authorized representative agrees to the fullest extent, to defend and hold the

company harmless for its failure to comply with the terms of this contract, all applicable

federal and state laws and regulations and specifically the insurance code of Puerto Rico,

its rules, normative and circular letters.

Section VIII. Applicable law and arbitration:

This agreement will be governed by the laws of the Commonwealth of Puerto Rico.

In the event of any dispute arising out of or under this agreement between the authorized

representative and the company that may not be in good faith resolved by the parties,

both agree to submit such disagreement to arbitration under the rules of the American

Arbitration Association.

Section IX. Nondisclosure of Confidential Information

Each party acknowledge that it will have access to certain confidential information of the

other party and, acknowledges that it may have access to and receive certain

information in relation to and including, but not limited to, marketing philosophy and

objectives, competitive advantages and disadvantages, the types of services provided to

insured’s, financial results, response results, technological developments, names,

addresses, telephone numbers and account numbers of customers and potential

customers, computer magnetic tapes, written or oral, technical, scientific management

and or marketing information and a variety of other related information and materials.

The receiving party agrees that all such information and materials considered

“Confidential Information” obtained by the other party its directors, officers, employees,

consultants and any third parties with whom it contracts, is, and shall be considered,

confidential and proprietary of the providing party.

The receiving party agrees that it shall:

(a) protect and preserve the confidential and proprietary nature of All Confidential

Information;

(b) not disclose, give, sell or otherwise transfer or make available, directly or

indirectly, any confidential Information to any third party for any purpose;

Agreement;

(d) limit the dissemination of the Confidential Information within its own organization

to individuals whose duties justify the need to know the Confidential Information,

and only with a clear understanding by such individual of their obligation to

maintain the confidential and proprietary nature of the Confidential Information

and to restrict its use solely to the purpose specified herein;

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(e) not make any records or copies of the Confidential Information, except as

required by this Agreement, and return al Confidential Information and any

copies thereof (in whatever form) immediately upon request.

(f) notify immediately of any loss or misplacement of records or copies of

Confidential Information; and

(g) Comply with any other security procedures reasonably established by the parties

with respect to the Confidential Information.

Each party shall ensure and guarantee compliance with the terms of this Agreement by its

directors, officers, employees, consultants and any third parties with which it contracts.

Each party agrees to protect the confidentiality of each party's customer information

Signed and effective at San Juan, Puerto Rico, this day ____ of ____________ , ____.

by______________________________ by__________________________

JOSE BENITEZ ULMER AUTHORIZED REPRESENTATIVE

PRESIDENT

Universal Life Insurance Representative

address: address:

PO Box 2145, San Juan PR 00922-2145 ______________________________

telephone: telephone:

(787) 706-7337 ______________________________

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ATTACHMENT A - COMMISSION SCHEDULE

UNIVERSAL LIFE INSURANCE COMPANY

TABLE OF AUTHORIZED REPRESENTATIVE ’S COMMISSIONS

(100% COMMISSION TO AGENCY )

As specified in this Table of Commissions, you will be paid the applicable commission that

applies to policies issued by the Company according to the insurance applications solicited and

sold by you in person and of which the payment of premiums are received by the Company.

On insurance policies issued by the Company in conformity with insurance applications solicited

and sold by your, and for which the premium payments have been received by the Company.

INSURANCE GROUP

 Group Life Insurance, Disability Insurance (LTD, STD, SINOT)

INDIVIDUAL INSURANCE

 Level Term 10-20-30-30ROP

 Level Term – Quick Term 10-20-30

 Funeral Expenses

INVESTMENTS PRODUCTS

 Fixed Annuity IRAS, and BONUS –

 Equity Index Annuity Universal (EIA 5 YR and Universal EIA 10 YR

Annual asset trail payments are payable quarterly after the 13th month of the contract

Chargebacks: For a surrender or lapse in the first twelve months after contract, policy issue,

commissions will be charged back 100%. In the event of surrender in any subsequent year no

amount will be charged back. The obligation to pay Universal Life Insurance Company any

amounts charged back survives the termination or expiration of the Appointment Agreement or

any other agreement.

Forfeiture of First Year Policies. Every first year policy forfeited after its issue date will have a

charge against the Authorized Representative in a sum equivalent to the paid and unearned

Commissions or Overriding Commissions.

CESSATION: In case of termination of this Contract for a Just Cause, as defined below, all first

year and renewal commissions will cease immediately.

a. A Just Cause to terminate this Contract will be considered as such, if it is the

perpetration of any of the following acts by You or any of your representatives or

assistants: a retention, rebate or embezzlement of funds belonging to the Company, the

violation of any of the dispositions of this Contract, the commission of a fraud or the

violation of any law or regulations of any state regulatory agency in which the Company

is established or authorized to carry on insurance business on the date of such violation;

and the dishonesty or misconduct due to which the reputation of the Company is or may

be impaired.

If the Contract is terminated for any other reason that is not included above, the

commissions herein specified will be paid, as accumulated to you, or your executor,

administrator or assignee.

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b. Upon termination of this Contract for any reason except for Just Cause, as defined

above, and independently of the amount of annual premiums in effect, all first year and

renewal commissions will be payable as earned on the basis of the percentage to which

You are entitled in conformity with the term of duration of the Contract: after three (3)

years from the date of this Contract, fifty percent (50%); after four (4) years, seventy five

percent (75%), and after five (5) years, one hundred percent (100%). However,

notwithstanding the above specifications, in no case will renewal commissions be paid

on policies that have been in effect from the issue date by the Company after their tenth

anniversary of premium payment, and in no case will renewal commissions be paid if the

total sum of the renewal commissions earned by You during the calendar year is less

than two hundred dollars ($200.00).

c. If this Contract is terminated because of Your death, the commissions and over riding

commissions pending payment will be paid to your estate or administrator, in conformity

with the ceding dispositions described in Section CESSATION B above, or under any

amendment or supplement to this Contract which modifies the provisions of Section

CESSATION B

d. All commissions and overriding commissions generated during the period of three years

previous to what is stipulated in Section: CESSATION: b of this Contract will be

retained by the Company in case you decide to cancel this agreement.

__________________ __ _______________________

Representative Agent Signature

____JOSE BENITEZ ULMER, ________________________ _____________________

by the Company Signature

UNIVERSAL LIFE INSURANCE COMPANY - LICENSING SERVICES AGENT DATA SHEET – LIFE

ALL INFORMATION IS REQUIRED UNLESS NOTED AS "OPTIONAL: (Please print or type)

Full Name: ______________________________________________________ Date of Birth: _______________

EXACTLY AS SHOWN ON LICENSE

State(s) to be Appointed in: __ License Number: ___________________ NPN: _____________________

Social Security Number:_____________________ NASD U-4 CRD number:_____ NASD Series Licenses: _______

If applicable If applicable

Postal Address: ___________________________________________________________________________

P O BOX

Resident Address: ______________________________________________________________________________

STREET ADDRESS

Telephone:(____)_____________________ Fax:(__)__________ E-mail ____________________________________

Business address_________________________Telephone:(___)____________E-mail ________________________

As we expand our means of communication, what is your single preference for receiving correspondence?  Mail  Fax  E-mail

Broker/Dealer/General Agent- Name: PHP AGENCY PUERTO RICO, LLC Commission 100% to general agent

name and signature person authorized :_________________________________

MUST BE COMPLETED BY AGENT:(Please attach a detailed letter of explanation for any "Yes" answer to the following

questions)

Have you ever been convicted of, pled no contest to, or are currently under indictment for any criminal felony or

Misdemean or excluding minor traffic violations? Yes No

Have you filed a bankruptcy petition, been declared bankrupt or insolvent within the past ten years? Yes No

Are you currently indebted to any insurance company or do you now have or have you ever had any unsatisfied

judgments, liens, or garnishments against you? Yes No

Have you ever had an appointment canceled by an insurance company for reasons other than lack of production? Yes No

Have you ever been suspended, disqualified or disciplined by any state, federal or self-regulatory agency? Yes No

I, , hereby authorize Universal Life and its agents to make an independent investigation of my background, references, character, past

employment, education, criminal or police records, including those mandated by both public and private organizations and all public

records for the purpose of confirming the information contained on my application and/or obtaining other information which may be

material to my qualifications for appointment.

I release Universal Life and/or its agents and any person or entity, which provides information pursuant to this authorization, from any

and all liabilities, claims or lawsuits in regard to the information obtained from any and all of the above referenced sources used.

I affirm that all of the information provided on the foregoing statement is true, accurate and complete to the best of my knowledge. Should

any of the information change, I will promptly notify Universal Life in writing.

REQUIRE DOCUMENTS:

_____Copy of the Insurance Commissioner license for the representative authorized.

_____Standards of Compliance: ANTI-MONEY LAUNDERING (Required evidence) and - RULE 93 FINANCIAL EXPLOITATION

AGAINST SENIORS.

I received the Rule 93 Financial Exploitation Against Seniors, the elderly and people with disabilities.

Representative Authorized signature _____________________________ date_______________

MAILING ADDRESS UNIVERSAL LIFE INSURANCE COMPANY, PO BOX 2145, SAN JUAN, PR 00922-2145 rev. 10/2015

FOR USE UNIVERSAL LIFE INSURANCE

Number: Effective: Agency Name:

_____________________ _____________________ __________________________________

Universal Life Insurance

Company

recognizes the importance

of protecting the adults, the elderly’s

and adults with disabilities from this

type of exploitation and be alert to

indicators of vulnerability and new

forms of financial exploitation.

Universal Life has established a

protocol for the prevention and

detection of cases of exploitation for

the benefit of those who need it most.

Universal Life Insurance Company

33 Bolivia St. Floor 6

San Juan, PR 00917

T: (787) 706-7337

www.miuniversalpr.com

www.lastenemostodas.com

For more information about this

topics you can contact:::

Departamento de la Familia

Tel: 787-294-4900

Departamento Procurador

de Personas de Edad Avanzada

y Adultos con Impedimentos

Tel: 787-749-1333

Policía de P.R

/ Puerto Rico Police

Tel: 787-343- 2020

Financial

Exploitation

OF ADULTS, ELDERLYS

AND ADULT WITH

DISABILITIES

Financial

Explotaition

OF ADULTS, ELDERLYS,

AND ADULTS WITH

DISSABILITIES

The Financial Exploitation is defined as the

misuse of the funds, property or resources of

a person with disabilities or elderly, by another

individual, including, but not limited to fraud,

false claims, and misappropriation of funds,

conspiracy, falsifying documents, coercion,

transfer property or denial of access to

property.

In several cases, the exploiter (a) is a member

of the family, a friend or somebody that you

know. The elderly person may also be victim

of care providers or other Trustees of trust

such as lawyers, accountants or financial

advisors.

¿HOW YOU CAN

IDENTIFY SUSPICIOUS

BEHAVIOR?

Whenever you interact with people of

advanced age or an adult with disability, we

must be alert and observe the behavior of the

person and his companion, if that’s the case.

Among the actions or behaviors that can be

identified as Suspicious Behavior or signals,

which can be identified as dangerous should

be considered.

A. Person of advanced age or adult with

disability that looks abandoned or

sloppy like is not receiving proper care.

B. Person of advanced age or adult with

disability visits a facility accompanied

and that companion ignore the life and

health conditions of this person.

C. Person of advanced age or adult with

disability doesn’t remember that he/she

applied for insurance, or doesn’t

remember details of the policy, and

shows confusion regarding the policy.

D. Person of advanced age or adult with

disability appears to be fearful of being

evicted or detained in an institution if he

doesn’t name as a beneficiary his/her

guardian, representative or any person

who is responsible for your care.

There is more than one person or

family that is requesting guidance,

insistently, on the benefits of insurance

to the person of advanced age or adult

with disability, without his/her consent.

F. There is more than one person or

family claiming to have guardianship

over the elderly or the adult with

disabilities and their goods.

G. The person who alleges having

custody or have been designated as an

authorized contact person, refuse to

show evidence of their authority or the

evidence that shows it is contradictory

and does not even seem legitimate.

IDENTIFICATION OF SUSPICIOUS

ACTIVITIES OF INSURANCE

BUSINESS

Between the insurance business activities

you can found:

A. Suspicious signatures on documents

related to policies.

B. The person of advanced age or adult

with disability manifests or looks like

doesn’t have knowledge of transactions,

claims, applications for insurance,

among other matters related to the

insurance business. .

C. Anyone requesting a change in the

residential or postal address that was

previously reported by the advanced age

person or adult with disability, without

the authorization of these.

D. Any person make consistent requests of

information regarding benefits and

beneficiaries that are assigned to the

policies, also ask for an application to

change beneficiaries.

E. Any person that is making consistent

requests of information regarding

benefits and beneficiaries that are

assigned to the policies, also ask for an

application to change beneficiaries.

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Universal Life Insurance Company

PO Box 2145 San Juan Puerto Rico 00922-2145

T: (787) 706-7337 F: (787) 793-1999 www.universalpr.com

RECEIPT DOCUMENT

I (last name and first name ) _________________________ representative of Universal Life

Insurance, confirm that I received today the brochure of financial exploit of older people,

elderly people and adults with disability, according to rule 93 issued by the

Commissioner of insurance of PR.

_____________________________________ _________________________

Signature date

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