UnitedHealthcare Assignment of Commission
This Agreement is entered into by and between UnitedHealthcare Insurance Company, on behalf of itself and
its affiliates (collectively, the "Company") and the undersigned, herein called the Assignor. The Assignor
hereby assigns to the Assignee all of the Assignor’s right, title, interest, claim or demand in and to any and all
compensation now due and payable, or which may become due and payable, under existing contracts and
agreements.
Assignor and Assignee agree to the following terms:
• Assignee, an individual or entity, must be contracted with the Company
• Assignor’s commissions for the writing id(s) specified below will be paid to the Assignee until Assignor
terminates this assignment by written notice to the Company
• Assignor has the right to terminate this assignment at any time with written notice to the Company
• Assignee has no right to terminate this assignment
• Assignee is responsible for chargeback debt accrued by the Assignor from the execution of this
assignment until termination, including appointment fee collection
• Assignor’s submission of this assignment of commission cancels any existing assignment of
commission, if applicable
• Assignee will receive the 1099 for payments received under this assignment of commission
• After commissions are assigned to Assignee, Assignor retains the obligation to pay any solicitors in its
downline
• Assignor and Assignee shall at all times defend, indemnify and hold harmless the Company and its
officers, agents, and employees from and against any and all suits, actions, losses, damages, claims,
expenses (including but not limited to the Company’s legal expenses) and liability of any character, type
or description arising out of the execution or performance of this assignment.
By signing below, the Assignor and Assignee agree to the terms of this assignment of commission.
From
Assignor Name ______________________________________ Assignor Writing ID(s) __________________
(Agent/Agency name - please print clearly)
Assignor Signature___________________________________ Date________________________________
To
Assignee Name______________________________________ Assignee Writing ID ____________________
(Agent/Agency name - please print clearly)
Assignee Signature___________________________________ Date________________________________
Send completed form to sh_commissions_administration@uhc.com
or fax to 866-761-9162
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