Fill - Free fillable Form 1.: Agent Agreement Great Western Insurance Company PDF form

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Agent Agreement

Great Western Insurance Company

PO Box 14410 • Des Moines, IA 50306 • (866) 252-5594

General Powers, Relationship, and Duties

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Compensation

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Term and Termination

Non-Replacement

Indemnity

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Legal Notices

If Agent is served with a legal notice on behalf of GWIC, Agent must notify GWIC immediately by telephone,

followed by certified mail.

Individual Guaranty

Venue

Agent’s Authorization for Release of Records

By signing this Agreement below,

10.

Fair Credit Reporting Act Consumer Disclosure

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11. Vector One

By signing this Agreement below, Agent acknowledges it has read the Vector One Debit-Check Agent/Agency

Authorization Form, attached hereto, and consents and authorizes Company and Vector One (for purposes of this

paragraph, each as defined in the Vector One authorization Form) to act in accordance therewith. Such consent and

authorization includes, but is not limited to, authorizing the Company to obtain and conduct an initial and ongoing

commission related debit balance screening through Vector One’s Debit-Check, report Agent’s commission related

debt upon termination of this Agreement, and Vector One to receive, process, and intentionally disclose to any Debit-

Check subscriber who submits an inquiry regarding Agent or Agent’s commission related debit balance information.

12.

No Waiver

13.

Entire Agreement

14.

Amendments

15.

Execution in Dual Capacity by Individual Agent

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16.

Execution and Effective Date

Official GWIC Office Use Only

Authorized Signature

Signed on (mm/dd/yyyy)

Acknowledgment of Section 7 Guaranty

I hereby agree to and accept the terms of Section 7 of the Agreement and further agree that all terms of this Agreement are fully

enforceable.

Individual Producer and/or Entity Authorized Signature

Signed on (mm/dd/yyyy)

Individual Producer Name (Printed)

Last Four Digits of Social Security Number

Guarantor Signature

Signed on (mm/dd/yyyy)

Guarantor Name (Printed)

Guarantor Address

If you completed both the Individual Agent and Entity sections of the Agent Demographic, then there must be a signature in both of the

areas below.

Entity Authorized Name (Printed)

Last Four Digits of Employer Identication Number

TO BE CODED UNDER

HST Insurance 1522192

Agent DemographicFE-AA-0618

*Applying as Individual Producer (Default)

Entity Both

First Name

Email (Required)

Middle Name Last Name

Street Address City ST Zip Code

State License Number Date of Birth (mm/dd/yyyy) Social Security Number

Sex: Male

Female

Cell Phone Number Oce Phone Number Fax Number

Agency Name

Email (Required)

Tax ID Number

Street Address

City ST Zip Code

Cell Phone Number

Oce Phone Number Fax Number

1) Complaint led against you with an Insurance Department

2) Felony conviction or violation of 18 U.S.C. § 1033

3) Filed Bankruptcy

4) Indebted to any Insurance Company / Agency / Manager

Yes, State:

Yes

Financial Institution Name (Bank Name)

Checking

Savings

(Contact your bank to verify EFT is allowed)

Routing Number (lower left corner of check)

Bank Account Number (lower left middle of check)

Commission payment (Default is Daily):

Daily

Bi-Weekly Monthly

(Attach copy of voided check)

*Individual Producer

*Entity

Background (Please explain, including dates, any “yes” answers on a separate sheet)

Direct Deposit (Please complete the information below)

Retain a copy of this form for your records. A copy will not be returned to you with the signature page of the Agreement.

Agent Demographic

Great Western Insurance Company

PO Box 14410 • Des Moines, IA 50306 • (866) 252-5594

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Debit-Check Agent/Agency Authorization Form

Vector One Operations, LLC dba Vector One (collectively with its affiliates, "Vector One") manages the secured web portal interactive computer

service provided by Debit-Check.com, LLC ("Debit-Check"). This Debit-Check Agent/Agency Authorization Form, incorporated by reference to

agency agreements and/or appointment paperwork with Medico Insurance Company, American Republic Insurance Services, and/or Great

Western Insurance Company and their affiliates, is used by Debit-Check subscribers who desire to be granted authorization from you for the

submission and/or receipt of your personal information to the Debit-Check service as necessary to conduct a commission related debit balance

screening. The undersigned company and its affiliates and authorized third parties (collectively, the "Company") is a Debit-Check subscriber.

Accordingly, as part of the contracting and appointment process or determination of eligibility for advancement of commissions, the Company

may conduct a commission related debit balance screening via Debit-Check in order to determine your eligibility and may continue to conduct

periodic commission related debit balance screenings as determined in the Company's sole discretion following the engagement of any

employment, appointment, contract, tenure, or other relationship with the Company.

Access to Debit-Check Information: You can obtain your commission related debit balance information by contacting the Vector One Agent

Hotline at (800) 860-6546.

AGENT/AGENCY’S STATEMENT – READ CAREFULLY

The Company is hereby authorized to obtain and conduct a commission related debit balance screening through Vector One's Debit-Check

secured web portal to determine if another Debit-Check subscriber has posted that I have an outstanding commission related debit balance. I

understand that the Company may consider the results of the commission related debit balance screening in order to determine my eligibility

to be contracted and appointed or determine my eligibility for advancement of commissions as an insurance producer and may continue to

conduct periodic commission related debit balance screenings as determined in the Company's sole discretion following the engagement of any

employment, appointment, contract, tenure, or other relationship with the Company. I understand and acknowledge that the Company may

obtain commission related debit balance information through Debit-Check as state law allows. I understand that my information, including my

name and social security number ("My Information") may be used for the purpose of obtaining and conducting a commission related debit

balance screening. I further understand that in the event of termination or expiration of my employment, appointment, contract, tenure, or

other relationship with the Company, whether voluntary or involuntary, if a commission related debit balance is owed to the Company, the

Company may post My Information to the Debit-Check service which may be accessed by Debit-Check subscribers until such time the debit

balance is satisfied or otherwise removed.

I HEREBY:

(A) Authorize the Company to use My Information for purposes of conducting a commission related debit balance screening, and

periodic commission related debit balance screenings as determined in the Company’s sole discretion following the engagement

of any employment, appointment, contract, tenure, or other relationship with the Company, utilizing Debit-Check.

(B) Authorize the Company to consider the results of the commission related debit balance screening in order to determine my

eligibility to be contracted and appointed or determine my eligibility for advancement of commissions as an insurance producer.

(C) Authorize and direct Vector One to receive and process My Information as necessary to intentionally disclose and furnish the

results of my commission related debt verification screening, whether directly or indirectly, to the Company.

(D) Authorize the Company to submit My Information to the Debit-Check service in the event of termination or expiration of my

engagement with the Company, whether voluntary or involuntary, to the extent a commission related debit balance is owed to

the Company.

(E) Authorize and direct Vector One to receive and process My Information and intentionally disclose to any Debit-Check subscriber

who submits an inquiry utilizing My Information the results of my commission related debit balance screening, which will contain

My Information, to the extent a debit balance is owed.

Form W-9

(Rev. December 2011)

Department of the Treasury

Internal Revenue Service

Request for Taxpayer

Identification Number and Certification

Give Form to the

requester. Do not

send to the IRS.

Print or type

See Specific Instructions on page 2.

Name (as shown on your income tax return)

Business name/disregarded entity name, if different from above

Check appropriate box for federal tax classification:

Individual/sole proprietor

C Corporation S Corporation Partnership

Trust/estate

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

▶

Other (see instructions)

▶

Exempt payee

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

City, state, and ZIP code

Requester’s name and address (optional)

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 the “Name” line

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

resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other

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

TIN on page 3.

Note. If the account is in more than one name, see the chart on page 4 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).

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 on page 4.

Sign

Here

Signature of

U.S. person

▶

Date

▶

General Instructions

Section references are to the Internal Revenue Code unless otherwise

noted.

Purpose of Form

A person who is required to file an information return with the IRS must

obtain your correct taxpayer identification number (TIN) to report, for

example, income paid to you, real estate transactions, mortgage interest

you paid, acquisition or abandonment of secured property, cancellation

of debt, or contributions you made to an IRA.

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

alien), to provide your correct TIN to the person requesting it (the

requester) and, when applicable, to:

1. Certify that the TIN you are giving is correct (or you are waiting for a

number to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S. exempt

payee. If applicable, you are also certifying that as a U.S. person, your

allocable share of any partnership income from a U.S. trade or business

is not subject to the withholding tax on foreign partners’ share of

effectively connected income.

Note. If a requester gives you a form other than Form W-9 to request

your TIN, you must use the requester’s form if it is substantially similar

to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are

considered a U.S. person if you are:

• An individual who is a U.S. citizen or U.S. resident alien,

• A partnership, corporation, company, or association created or

organized in the United States or under the laws of the United States,

• An estate (other than a foreign estate), or

• A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or

business in the United States are generally required to pay a withholding

tax on any foreign partners’ share of income from such business.

Further, in certain cases where a Form W-9 has not been received, a

partnership is required to presume that a partner is a foreign person,

and pay the withholding tax. Therefore, if you are a U.S. person that is a

partner in a partnership conducting a trade or business in the United

States, provide Form W-9 to the partnership to establish your U.S.

status and avoid withholding on your share of partnership income.

Cat. No. 10231X

Form W-9 (Rev. 12-2011)

PO Box 9160

Ogden, UT 84401

www.gwic.com

Toll-Free 1-866-252-5594

INSURANCE COMPANY

Producer Training Guide to Anti-Money Laundering Requirements

under the USA Patriot Act

The Patriot Act: What Is It?

The USA Patriot Act was enacted to better protect the ﬁnancial system from potential abuse by criminals and terrorists. Generally, the Act requires

the Department of the Treasury to set standards for anti-money laundering (AML) programs. These standards were developed by the Financial

Crimes Enforcement Network (FinCEN), the agency under the Department of the Treasury responsible for safeguarding the ﬁnancial system from

the abuses of ﬁnancial crime. The regulations developed by FinCEN require insurance companies to establish AML programs meeting certain

requirements, including the reporting of suspicious transactions. In issuing the regulations, FinCEN speciﬁcally noted that insurance agents and

brokers (“producers”) are expected to play an important role in a ﬁnancial institution’s AML program.

What Is Money Laundering?

Money Laundering is generally deﬁned as the process of using various techniques to move illegally acquired cash through ﬁnancial systems so that

it appears to be legally acquired cash. The goal of a money laundering operation is usually to hide either the source or the destination of the money.

The money laundering process is comprised of 3 overlapping phases:

Placement: this is the physical disposal of cash into the ﬁnancial system. The simplest example is making a bank account deposit.

Layering: this involves carrying out complex ﬁnancial transactions to camouﬂage the illegal source of the cash.

Integration: this is the ﬁnal stage whereby the money is placed back into circulation in an apparent legitimate form.

What Is Terrorist Financing?

Terrorist activity ﬁnancing may involve funds raised from legitimate sources to fund illegal activities. Because the transactions are often lawfully

obtained and tend to be in smaller amounts than those associated with money laundering, they are generally more difﬁcult to identify. However,

many of the Red Flags for money laundering are the same as those for terrorist ﬁnancing and will also help you discover this type of illegal activity.

What Products Are Affected by AML Laws?

FinCEN has identiﬁed the following categories of “covered products” that present risk for money laundering. These covered products include the

following:

• A permanent life insurance policy, other than a group life insurance policy;

• An annuity contract, other than a group annuity contract; or

• Any other insurance product with features of cash value or investment

Term life insurance, health insurance, and other types of non-cash value products are excluded from the AML regulations.

What Are “Red Flags”?

You must notify the AML Compliance Ofﬁcer if you detect any money laundering Red Flag activities so the Company can investigate and determine

whether a suspicious activity report must be ﬁled with the government. Examples of Red Flags include the following:

• Multiple accounts sharing a beneﬁciary

• Failure to properly identify the owner

• The insurance product purchase appears to be inconsistent with the customer’s needs

• The purchase or funding of a product appears to exceed a customer’s known income or liquid net worth

• Any attempted unusual method of payment, particularly by cash or cash equivalents, such as money orders or cashier’s checks

• Payment of a large amount broken into small amounts to avoid mandatory reporting thresholds

• Customer shows little or no concern for the investment performance of the product, but much concern about the early termination features

of the product

• Reluctance from a customer to provide identifying information or providing minimal or seemingly ﬁctitious information

• Designation of beneﬁts to an unrelated third party

43 115 3750 0418 US

• The customer requests early termination of an insurance product, especially at a cost to the customer, or where cash was tendered and/

or the refund check is directed to an apparently unrelated third party

• The transfer of the beneﬁt to an unrelated third party

• The borrowing of the maximum amount available soon after purchasing the product

What Are My Responsibilities as a Producer?

As a producer, you play an important role in discovering whether money is coming from an illegal source. Your direct contact with the customer

places you in a unique position to gather information and detect suspicious activity using Red Flags. In fact, in the preamble of the regulations, Fin-

CEN states, “insurance agents and brokers are an integral part of the insurance industry due to their contact with customers. Insurance agents and

brokers typically are involved in sales operations and are therefore in direct contact with customers. As a result, the agent or broker will often be in

a critical position of knowledge as to the source of investment assets, the nature of the client and the objectives for which the insurance products

are being purchased.”

As a producer selling covered products, you are responsible for the following:

1. Obtaining and providing complete and accurate information in all applications and other documentation required for issuance of a covered

product or a transaction involving a covered product, which includes, but is not limited to, the following:

a. Name

b. Tax Identiﬁcation Number / Social Security Number

c. Address

d. Date of Birth

2. Verifying the customer’s identity and notifying the AML Compliance Ofﬁcer if a customer, when requested, refuses to provide information or

provides false or misleading information. In order to verify a customer’s identity, you should:

a. Request an unexpired, government-issued form of identiﬁcation bearing a photograph, such as a driver’s license, US passport, state

photo ID, or resident alien identiﬁcation card;

b. Conﬁrm that the photograph matches the customer; and

c. Conﬁrm address, date of birth, and other personal information; and

d. Record the customer’s identifying information on the application as it appears on the customer’s identiﬁcation.

3. Communicating restrictions to clients on acceptable payment prior to accepting payment, returning any unacceptable form of payment

immediately, and notifying the AML Compliance Ofﬁcer regarding any difﬁculties encountered. Please remember that Great Western Insurance

Company cannot accept cash for premium payments. Refer to the Agent Field Manual for further discussion of restrictions to payment

methods.

4. Immediately notifying the AML Compliance Ofﬁcer of the presence of any Red Flags at the time of application or during any interaction with

clients.

5. Maintaining an accurate record of information collected to identify a customer and the methods used to resolve any concerns about the

documentation.

6. Cooperating with the AML Compliance Ofﬁcer in performing any investigations necessitated by the presence of any Red Flags that may arise

concerning a covered product.

How Do I Notify the AML Compliance Ofﬁcer?

If you detect or are concerned about a Red Flag event, you should contact the AML Compliance Ofﬁcer at 1-800-773-5454, extension 2364. If you

are unsure if an event qualiﬁes as a Red Flag event, you should contact the AML Compliance Ofﬁcer.

I certify that I have read and understand this Producer’s Training Guide to Anti-Money Laundering. I understand that under the Treasury Department

and its Financial Crimes Enforcement Network (FinCEN) have issued regulations requiring insurance companies to establish AML programs meeting

certain requirements as well as report suspicious transactions, and that as an insurance agent, I am expected and agree to comply with these

requirements.

Agent Signature

Agent Number

Date

AGREEMENT

It is agreed by and between Diversified Insurance Brokers, Inc. (hereafter referred to as “Diversified”),

and the Person, Persons or Agency stated below (hereafter referred to as “Producer”) that in consideration

of Diversified’s continued goodwill and patronage.

A. Producer agrees to obtain and maintain from the date of this Agreement forward, at Producer’s

expense, liability insurance coverage from an insurance carrier licensed to do business in the

State of applicable jurisdiction. This insurance coverage will include protection against any

errors or omissions on the part of Producer and/or his or her Agents and/or Employees. Producer

agrees to provide proof of such insurance to Diversified (complete reverse side of this

Agreement) and to furnish Diversified with a copy of the applicable insurance policy (or policies)

upon the request of Diversified.

B. In the event Producer does not obtain and maintain the liability insurance protection requested in

paragraph “A”, Producer agrees to hold Diversified harmless and indemnify Diversified against

any and all liability, loss, damages, judgments, costs or expenses of any nature, type or kind

(including reasonable attorney’s fees) incurred by Diversified or imposed upon Diversified as a

result of any allegedly wrongful or torturous act or omission on the part of Producer and/or his or

her Agents and/or Employees.

C. In the event Diversified is required to refund or return to the Insurer any commission or fee paid

or credited to Producer, Producer will reimburse Diversified for this payment in full within thirty

(30) days of the date of request for such payment. This also includes any advanced commission to

any agent, corporation, partnership or sole proprietorship acting as an agent.

As long as any debit balance (advanced commissions) exists with a carrier, Producer agrees that

no attempt will be made to replace business written under that carrier’s contract within thirty six

(36) months of termination of Producer’s contract, or for the length of carrier’s contract

provision, whichever is greater.

In the event of Litigation to determine the respective rights, duties, and/or obligations of

Diversified or Producer under this Agreement, the prevailing party shall be entitled to reasonable

attorney’s fees.

Producer agrees that this agreement is applicable to any and all companies he or she is contracted

with through Diversified Insurance Brokers, Inc.

Producer certifies that the information provided in this Agreement is correct and complete.

Diversified Insurance Brokers, Inc. ___________________________Date____________

Producer (signature) _____________________________________Date______________

Producer (print name) ______________________________________________________

Note: A. Sign Page 1 Only if you DO NOT have Errors & Omissions Insurance.

B. Sign Page 1 And page 2 if you DO have Errors and Omissions Insurance.

April 1, 2010

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VERIFICATION OF ERRORS & OMISSIONS INSURANCE COVERAGE

Producer Name ______________________________________________________________

Producer Agency Name _______________________________________________________

Name of Producer’s Current Errors & Omissions Carrier

(if NONE, please so state): _______________________________________________

Current Policy Number __________________________________________________

Effective Date of Current Coverage ________________________________________

Limit of Liability _______________________________________________________

__________________________________________ EACH CLAIM

__________________________________________ AGGREGATE

Retroactive ____________________________________________________________

Deductible ________________________________________________ EACH CLAIM

The policy described above will remain in effect until the expiration date shown and then

be renewed with the same limits. Should this policy be cancelled or non-renewed, Producer will

immediately notify Diversified Insurance Brokers, Inc. (Diversified).

Producer (signature) ___________________________________________Date_____________

NOTE: Sign Page 1 AND 2, if you DO have Errors & Omissions Insurance. Please complete

upper portion of this page giving detail of your Errors & Omissions policy. We will also need a

copy of your policy declaration page.

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Great Western Insurance Company

License Only Agent (LOA) Notification

EFFECTIVE DATE: 7/1/2020

You represent Great Western Insurance Company (GWIC) as a Licensed Only Agent (LOA). As a result,

and pursuant to Section 2.c. of the Agent Agreement, GWIC is not obligated to you for commissions,

expense allowances or any form of compensation whatsoever in connection with the services performed

and expenses incurred by you in the solicitation of applications for insurance issued by Company.

You are contracted directly to or otherwise have an agreement with your upline to compensate you

directly for such services. By submitting business to Company, you expressly agree to the above

statements.

Should you have any questions regarding this document, please contact your upline.

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Fillable Form 1.: Agent Agreement Great Western Insurance Company

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