Fill - Free fillable CHECKLIST and its affiliated companies (collectively ISC), looks PDF form

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Dear Producer:

Integrated Specialty Coverages LLC

and its affiliated companies (collectively ISC), looks forward to

doing business with your agency and beginning a good working relationship.

CHECKLIST

Legible copy of your current broker’s license

Legible copy of your broker’s bond (if applicable)

Copy of your current E & O Policy declaration page

Completed brokerage contract

Completed Producer Questionnaire

Completed W-9 Form

Please send the completed information to:

Attention Marketing

E-mail: info@iscmga.com

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PRODUCER

QUEST

ONNA

PAGE 1 OF 2

Legal Agency Name:

*Must match licensed name and W9

DBA:

Mailing Address: City:

State: Zip:

Physical Address: City:

State: Zip:

Website Address:

Phone Number: ( ) - Fax Number: ( ) -

Agency Type: __Retail __Wholesale __Both

Agency is a: __Partnership __Sole Proprietorship __Corporation __S-Corporation

Date Agency Established: FEIN or SSN:

Name and addresses of all persons having an ownership interest in agency. Please attach additional sheets

if necessary.

Name of Owner/Principal

NPN Number

Email address of Owner/Principal

Home Address: City:

State: Zip:

Total Number of employees: Number of Producers:

Requested OnlineMGA User Accounts: (Name / Title / Email / NPN Number / Admin Rights (Yes / No)

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PRODUCER

QUEST

ONNA

PAGE 2 OF 2

Have you or anyone in your agency been sued concerning insurance related activities?

__Yes __No If yes, please explain on a separate sheet and attach this form.

Have you, your employees, or your agency been disciplined by any State Agency or Department of

Insurance?

__Yes __No If yes, please explain on a separate sheet and attach this form.

Have any Error & Omission claims been made in the most recent five years against your

agency, officers, partners or owners?

__Yes __No If yes, please explain on a separate sheet and attach this form.

Financial Information:

Bank Name:

Mailing Address: City:

State: Zip:

Trust Account #: Average Balance: $:

Do you have overdraft protection: __Yes __No

Please list companies and MGAs you place business with in order of premium volume:

Carrier/MGA: Annual Premium: Loss Ratio:

It is agreed that the statements on this application or any material submitted herewith are true and

accurate representation of the applicant and they shall be deemed material to the acceptance of

risk(s) from the brokerage by Integrated Specialty Coverages LLC.

Name (Please print): Title:

Must be signed by agency principal

Signature: Date:

How did you hear about us?

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LIMITED PRODUCER AGREEMENT

THIS PRODUCER AGREEMENT (the “Agreement”) is made as of ____________________ by and between,

Integrated Specialty Coverages LLC., its subsidiaries, and affiliated companies, (hereinafter collectively

referred to as “ISC”) and ________________________________ (hereinafter referred to as “Producer”).

WHEREAS, ISC is in the business of placing contracts on behalf of insurance carriers ("Carrier"); and

WHEREAS, Producer desires to submit insurance applications on behalf of its customers to ISC to be placed

with Carrier, subject to all of the terms, conditions, and restrictions contained herein.

NOW, THEREFORE, for valuable consideration, the receipt and sufficiency of which is hereby acknowledged,

the parties agree as follows:

Article I - Authority

Section 1.1. ISC grants Producer the non-exclusive right to submit proposals for insurance covering such

classes of risks as ISC may, from time to time, authorize in writing to be insured. Producer may issue quotes

on behalf of ISC only as authorized by ISC. Producer is not authorized to accept or bind ISC or any Carrier

represented by ISC to any quote, binder, policy or endorsement or amend, modify or alter the terms of any

policy placed by Producer except as permitted by ISC. The only authority provided to Producer under this

Agreement is to submit applications and premiums to ISC. At all times during the term of this Agreement,

Producer agrees in good faith to use its best efforts to increase the volume of submissions for insurance to ISC

by actively marketing and selling ISC’s products.

It is understood and agreed that in carrying out its duties under this Agreement, Producer is acting as an

independent contractor representing the interests of applicants and policyholders. Nothing herein shall be

construed to make Producer an agent of ISC in fact or by operation of law. In recognition of Producer's status

as an independent contractor, the parties agree that this Agreement is not a contract of employment and does

not create any kind of employment relationship. Producer's relationship to ISC is solely that of an independent

contractor.

Section 1.2. Producer may charge producer fees, broker fees or other charges for services provided in

connection with policy transactions only to the extent and in the amount allowed by law in the state where the

risk is located. The determination of such fees and responsibility are solely that of Producer.

Section 1.3. Producer is not authorized to extend credit or financial terms to an insured. Producer agrees that

if Producer extends credit or financial terms to an insured, Producer shall be responsible to pay ISC and or the

Carrier all amounts due ISC or the Carrier whether or not Producer has collected these amounts from the

insured.

Section 1.4. Producer has no authority to cancel coverage, assign any losses or adjust any losses on behalf of

ISC or Carrier. All claims are to be reported to the party specified by ISC or Carrier.

Article II - Accounting

Section 2.1. Producer is responsible for payment of all premiums due on binders, policies and endorsements

issued by ISC on behalf of the Carrier and at the request of Producer. As used herein, premium means policy

premium, additional premium on audits and inspections and unearned commission on cancelled binders,

policies and endorsements. Producer shall pay all premium, including earned premium on cancelled binders,

policies and endorsements when due, whether or not such premium has been collected by Producer.

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All premium and return premium received by Producer on policies issued by ISC on behalf of the Carrier shall

be held by Producer in a fiduciary capacity and in trust for ISC until such time as the Premium is paid to ISC,

or, in case of unearned premium, returned to the policyholder. All premiums collected by Producer shall be

deposited into a premium trust account maintained solely and exclusively for that purpose, except as allowed

by law. No sums may be withdrawn from such account other than to remit premium due to ISC and to pay

commissions earned by Producer, except as otherwise allowed by law. Producer shall have no ownership

interest in the premium in such account, however, to the extent allowed by law and with ISC’s prior approval,

Producer may establish an interest bearing premium trust account and retain the interest earned thereon.

In the event Producer is relieved of the obligation to pay premium as provided herein, no commission shall be

payable to Producer.

Article III - Ownership of Expirations

Section 3.1. During the term of this Agreement or upon the expiration or early termination thereof, provided

that Producer has fully complied with all of the provisions thereof, the ownership, use and control of

expirations, and the records of Producer pertaining thereto, shall be vested in Producer. If ISC terminates this

Agreement due to a material breach by Producer, the ownership, use and control of expirations shall be vested

in ISC as of the effective date of termination. For purposes of this Section, material breach means and includes

but is not limited to (1) Producer’s failure to pay premium as required under the terms of this Agreement; (2)

Producer’s license is suspended or revoked by a regulatory agency; (3) Producer becomes insolvent, files for

bankruptcy, or goes into receivership; (4) Producer violates any law(s) applicable to the transaction of business

covered by this Agreement; (5) Producer’s violation of any fiduciary duty or duty of loyalty owed to the ISC or

acts of dishonesty or (6) Producer fails to perform or breaches any of its obligations under this agreement. If

ISC terminates this Agreement with the intent to assume ownership of the expirations, ISC will provide 15 days

prior written notice to Producer. During the 15 day period, Producer may prevent the transfer of ownership by

curing such material breach within that time or, in the event that Producer disagrees that it materially breached

the Agreement, seeking judicial intervention to prevent the transfer of ownership.

Article IV – Commission and Expenses

Section 4.1. Except as otherwise agreed by the parties, all commissions due and payable under the Producer

Agreement shall be paid to Producer by ISC on premiums (excluding taxes and fees) that are actually paid to

ISC or its Carrier in valid and collectable funds for policies ordered through ISC by Producer. The commission

rate payable to Producer for such policies shall be determined by ISC on a policy-by-policy basis and shall be

specified in each quote for insurance and invoice provided to Producer by ISC. Producer’s acceptance of the

commission rate specified in its insurance quote is deemed complete at the time the policy is bound, unless

Producer notifies ISC in writing prior to requesting that coverage be bound, and ISC agrees in writing to

change the rate of commission. The commission rates may be modified from time to time in the sole discretion

of ISC. Commissions are payable only on premium remitted to ISC by Producer. Producer will refund unearned

commission on cancelled binders, policies or endorsements to ISC within thirty (30) days after notice of policy

cancellation. Unearned commission shall be refunded by Producer at the same percentage rate as the

commission was originally paid.

Article V - Reporting

Section 5.1. Producer shall promptly report all requests from policyholders for changes or modifications to

policies, binders, and endorsements on policies placed by Producer under this Agreement.

Section 5.2. Producer shall promptly report claims and losses on policies placed by Producer under this

Agreement. Producer has no authority to refer claims and losses to third-parties for investigation or adjustment

or to negotiate settlement of any claims and losses on behalf of ISC. Producer will cooperate fully with ISC,

Carrier or their adjusters, attorneys, or others in the investigation, adjustment, settlement, or payment of any

claim or loss on policies placed by Producer under this Agreement.

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Article VI - Compliance

Section 6.1. Producer represents that it is a duly licensed insurance agent and/or broker and that it along with

its employees, agents and contractors engaged in the solicitation, negotiation and placement of insurance

under this Agreement are duly licensed as required by law in the state(s) where the risk(s) is located. Producer

and its employees, agents and contractors warrant that they will maintain all such licenses in good standing

during the term of this Agreement.

Section 6.2. Fees may be charged by Producer on policies issued under the Producer Agreement only as

permitted by law in the state where the risk is located. ISC shall have no ownership interest in or right to retain

any fees collected on behalf of Producer. ISC is not responsible or liable for filing or payment of any Federal,

state or local taxes, assessments or surcharges of any kind on fees collected on behalf of Producer. Producer

represents and warrants that it is, and will remain, in full compliance with all laws and regulations applicable to

fees charged on policies issued by ISC or the Carrier under the Producer Agreement.

Section 6.3. Producer shall provide each insured with the applicable policy documents, along with a full and

complete explanation of the terms, conditions and provisions of the policy of insurance, including but not limited

to, coverage being afforded, amendments, endorsements, exclusions and any other such information affecting

the policy of insurance. Upon submittal of the final policy documents to Producer, he shall then deliver to the

insured, all policy documents, including but not limited to, the policy, endorsements, or any other such documents

effecting coverage. The coverage type, amounts and insurance needs of the insured are the sole responsibility of

the Producer.

Section 6.4. Producer shall NOT have authority to appoint subproducers.

Article VII – Suspension and Termination

Section 7.1. ISC may, by written notice to Producer without terminating this Agreement, suspend the authority

of Producer to exercise any or all of the rights granted to Producer hereunder.

Section 7.2. This Agreement may be terminated immediately by ISC at any time upon the occurrence of any of

the following: (1) Producer commits a material breach of this Agreement; (2) Producer violates any law(s)

applicable to the transaction of business covered by this Agreement; or (3) Producer becomes insolvent,

declares bankruptcy, goes into receivership or has its license suspended or revoked by any regulatory agency.

Section 7.3. At its sole option, ISC may terminate this Agreement with ten (10) days prior written notice if

Producer is acquired by or merges with another person or entity regardless of whether Producer is the

surviving party, or upon the sale of more than fifty percent (50%) of the assets or voting interests of Producer

or if Producer fails to give notice of a change in ownership as required per this agreement.

Section 7.4. This Agreement may be terminated by either party without cause with not less than sixty (60)

days prior written notice to the other party stating the effective date on which this Agreement shall be

terminated.

Article VIII – Service Marks and Advertisements

Section 8.1. Producer may not use, in any form, the name, trade mark, trade name or service mark of ISC or

its parent or affiliated companies without the prior written consent of ISC.

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Article IX – Insurance

Section 9.1. During the term of this Agreement, Producer shall maintain errors and omissions insurance

coverage with limits of liability not less than One Million Dollars ($1,000,000.) each claim and in the aggregate

with defense costs outside of policy limits.

Producer hereby verifies that such coverage is in effect and Producer agrees to provide the certificates of

insurance evidencing the coverages required by this section, upon request. Such insurance shall be

maintained by the Producer at its sole cost and expense. This insurance shall be primary and noncontributing

coverage not withstanding any valid and collectible insurance available to ISC.

Article X – Indemnification

Section 10.1. With the exception that the following provisions of this section shall in no event be construed to

require indemnification by Producer in excess of that permitted under the public policy and law of the State of

risk, Producer shall immediately defend, hold harmless and indemnify ISC, including its employees, agents,

subsidiaries, affiliated companies, underwriting companies, claim adjusting companies or Carrier from and

against all loss, claims, demands, causes of actions, complaints, regulatory matters, petitions, damages, costs,

attorney’s fees, fines, or liabilities, in law or in equity, of every kind and nature whatsoever, that arise from or in

any manner are directly or indirectly connected with the performance of this Agreement. Producer’s obligations

hereunder shall survive termination of this Agreement.

Notwithstanding the above, such indemnity obligations shall not apply to matters involving the sole negligence

or willful misconduct of ISC.

Article XI – Miscellaneous

Section 11.1. Amendments. This Agreement may only be amended, supplemented or modified by a written

instrument, signed by the party against which the enforcement of the amendment, modification, or supplement

is sought.

Section 11.2. Notices. All notices; demands and other communications which may be given hereunder shall

be in writing to the respective parties as follows:

ISC: 1811 Aston Ave, Suite 200, Carlsbad, CA 92008

Attention: Legal Department

Producer: ___________________________________

Attention: ___________________________________;

or to such other address as the parties may from time to time designate by prior written notice to the other.

Section 11.3. Right of Offset. ISC shall have the right of offset for any and all amounts owed by Producer to

ISC, whether incurred under this Agreement or any other agreement, audit or any other financial transaction

between the parties hereto or between Producer and any other affiliates of ISC. ISC is authorized to deduct

from and offset any amounts owed by Producer to ISC or its affiliates before paying any amounts due to

Producer under this Agreement.

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Section 11.4. Governing Law. This Agreement shall be governed by and construed in accordance with the

laws of the State of California. Venue for any action, arbitration or other proceedings shall be San Diego,

California. Any provision of this Agreement that is contrary to the controlling law is hereby deemed to be

amended to bring it in compliance with that law. The determination by a court or arbitrator of competent

jurisdiction that any provision of this Agreement is unenforceable will in no way impair or affect the validity or

enforceability of any other provision of this Agreement.

Section 11.5. Attorney Fees. In the event of any dispute between the parties arising out of this Agreement,

the party prevailing in any legal action or proceeding shall be entitled to recover from the other its costs and

expenses thereof, including, its reasonable attorneys’ fees, costs and expenses.

Section 11.6. Changes in Ownership and Assignment. The Producer agrees to provide timely notice to ISC

of any anticipated or planned changes in ownership. For purposes of this section, a change in ownership

means (1) the acquisition of or merger with another entity, whether or not the party giving notice will be the

surviving entity, or (2) a sale of more than 50% of the assets or voting interests of the party giving notice.

Notice under this section shall be given as soon as practicable but not less than ten (10) days after a letter of

intent or other preliminary agreement for such change in ownership is completed. Neither this Agreement nor

any rights hereunder may be assigned by Producer without the prior written consent of ISC.

Section 11.7. Confidential Information. ISC and Producer agree not to use or disclose “Confidential

Information” except as required to perform their duties and obligations under this Agreement and in

accordance with applicable privacy laws. As used herein, the term “Confidential Information” means proprietary

business information and non-public individual personal and financial information belonging to ISC, Producer

and/or policyholders.

The term “Confidential Information” DOES NOT INCLUDE information which (1) was or becomes generally

available to the public, or (2) becomes available to a party from a source other than the disclosing party. If a

party becomes legally compelled to disclose any “Confidential Information”, such party shall provide the other

party with prompt written notice of any such requirement, before making any such disclosure.

Section 11.8. Communication. By executing this Agreement, Producer grants ISC the right to communicate

with Producer via telephone, facsimile transmission, e-mail and/or regular mail for the purposes of transacting

business under this Agreement. Such communication may include but is not limited to unsolicited advertising

material.

Section 11.9. Final Agreement. This Agreement constitutes the entire agreement between the parties with

respect to the subject matter of this Agreement and supersedes all prior agreements, oral and written, between

the parties hereto with respect to the subject matter of this Agreement.

Section 11.10. Successors. This Agreement will be binding on and will inure to the benefit of the parties and

their respective successors and permitted assigns. Except as provided in this Section, neither this Agreement

nor any rights or duties hereunder may be assigned or delegated by Producer without the prior consent in

writing of ISC.

Section 11.11. Waiver. ISC’s failure to insist upon strict compliance with any of the provisions of this

Agreement or the underwriting guidelines will not constitute continuing waiver of the right to insist upon such

compliance.

Section 11.12. Severability. In the event any provision of this Agreement is deemed to be invalid, illegal, or

unenforceable, all other provisions of the Agreement that are not affected by the invalidity, illegality, or

unenforceability shall remain in full force and effect.

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Section 11.13. Counterparts. This Agreement may be executed in counterparts with the same effect as if all

original signatures were placed on one document, and which, when taken together, shall constitute one original

agreement. Moreover, this Agreement may be executed by facsimile, email and/or other electronic signature.

IN WITNESS WHEREOF, the parties hereto, each acting under due and proper authority, and intending to be

legally bound, have executed this Agreement as of the day, month, and year first above written.

Integrated Specialty Coverages LLC

By:

Date:

PRODUCER:

Signature: Date:

Print Name:

Title

Form W-9

(Rev. October 2018)

Department of the Treasury

Internal Revenue Service

Request for Taxpayer

Identification Number and Certification

▶

Go to www.irs.gov/FormW9 for instructions and the latest information.

Give Form to the

requester. Do not

send to the IRS.

Print or type.

See Specific Instructions on page 3.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the

following seven boxes.

Individual/sole proprietor or

single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)

▶

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check

LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is

another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that

is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Other (see instructions)

▶

4 Exemptions (codes apply only to

certain entities, not individuals; see

instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)

(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.) See instructions.

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid

backup withholding. For individuals, this is generally your social security number (SSN). However, for a

resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other

entities, it is your employer identification number (EIN). If you do not have a number, see How to get a

TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and

Number To Give the Requester for guidelines on whose number to enter.

Social security number

– –

Employer identification number

–

Part II Certification

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue

Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am

no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because

you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,

acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments

other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Sign

Here

Signature of

U.S. person

▶

Date

▶

General Instructions

Section references are to the Internal Revenue Code unless otherwise

noted.

Future developments. For the latest information about developments

related to Form W-9 and its instructions, such as legislation enacted

after they were published, go to www.irs.gov/FormW9.

Purpose of Form

An individual or entity (Form W-9 requester) who is required to file an

information return with the IRS must obtain your correct taxpayer

identification number (TIN) which may be your social security number

(SSN), individual taxpayer identification number (ITIN), adoption

taxpayer identification number (ATIN), or employer identification number

(EIN), to report on an information return the amount paid to you, or other

amount reportable on an information return. Examples of information

returns include, but are not limited to, the following.

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual

funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross

proceeds)

• Form 1099-B (stock or mutual fund sales and certain other

transactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest),

1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident

alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might

be subject to backup withholding. See What is backup withholding,

later.

Cat. No. 10231X

Form W-9 (Rev. 10-2018)

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