Contract Information and Signature Form
If contracting as a: Producer only - complete sections 1, 3 & Individual FCRA Authorization Form
Business Entity only - complete sections 2 & 3
Business Entity & Principal- complete sections 1, 2, 3 (both signature blocks) & Individual FCRA Authorization Form
Producer Information (Required)
Name: SSN: - - DOB: - -
First Name, Middle Initial, Last Name (as it appears on license) MM DD YYYY
Not a P.O. Box City State Zip Code
P.O. Box Accepted City State Zip Code
Primary Phone Number: - - Business Phone: - - Email Address:
y (If applicable):
(As Required): $
Background Information (Required - Must be answered)
Carrier Name Minimum $1M Per Claim
Has any regulatory authority, such as an insurance department, FINRA or the SEC ever fined or suspended you,
placed you on probation, assessed you any administrative costs, entered into a consent order with you, issued
you a restricted license, or otherwise disciplined you? Are you currently under investigation by any regulatory
authority, such as an insurance department, FINRA or the SEC?
Other than minor traffic offenses that did not result in harm to a person or property, have you been (1)
convicted of any offense, or (2) pled guilty or nolo contendre (no contest) to any offense?
NOTE: Answering “YES” to the above questions does not automatically preclude you from being contracted.
If Yes, please include county _____________________________________________________________________
Directions: PLEASE PROVIDE A WRITTEN EXPLANATION for any “YES” answer including the disposition and applicable supporting documentation (court documents,
insurance department documents etc.). Failure to answer “YES”, when appropriate, may result in denial of your request to be contracted.
Contracting Selection (Required)
Direct Deposit Information (Complete if you are electing direct deposit - not applicable for Special Agents)
Account Number: Account Type Checking Savings
This is not an assignment of commissions. Form 1099 will be issued to the commission owner.
Express Pay Opt In
Eligibility requires Direct Deposit, Electronic Statements and no active Legal Judgments. Express Pay may not be available for all Marketers.
Express Pay is calculated every day. (If unselected, default pay cycle is Weekly.)
Designation of Beneficiary (if applicable)
First Name, Middle Initial, Last Name or Business Name
Not a P.O. Box City State Zip Code
SSN: - - or TIN: - DOB: - - Phone Number: - -
Taxpayer Identification Number (SSN)
Enter your TIN in the appropriate box. For individuals, this is your social security number. For other entities, it is your employer identification number.
Social Security Number --- ---
Under penalties of perjury, I certify that:
1. The number provided is my correct taxpayer identification number, 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
3. I am a U.S. person (a U.S.
citizen or U.S. resident alien or a partnership, corporation, company or association created or organized in the U.S. or under the laws of the
U.S. or an estate (other than a foreign estate) or a domestic trust (as defined in Regulations section 301.7701-7).
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
o report all interest and dividends on your tax return.
The Internal Revenue Service does not require your consent to any provision of this document other than the above-referenced
certifications required to avoid backup withholding.
****Please proceed to Section 3****
I have received, reviewed and agree to be bound by the Terms & Conditions of the General Agent Agreement with
Mutual of Omaha and its
Please retain a copy of the agreement for your files. A copy will not be returned to
I have received, reviewed and agree to be bound by the Terms & Conditions of the
with Mutual of Omaha and its
Please retain a copy of the agreement for your files. A copy will not be returned to you.