Fill and Sign the Exclusive Agreement Form

Exclusive Agreement Between Employer and Broker to Secure Group Insurance Agreement made on _____________________________________________ (date) , between _______________________________________________________ (Name of Broker) of ___________________________________________________________________________ ______________________________________________________________________________ _________________________________ (street address, city, county, state, zip code) , referred to herein as Broker, and __________________________________________________________ (Name of Employer), a corporation organized and existing under the laws of the state of __________________________________________________, with its principal office located at ______________________________________________________________________________ ______________________________________________________________________________ __________________________________ (street address, city, county, state, zip code) , referred to herein as Client. Whereas, Client desires to obtain group (e.g., health, life and/or disability) ______________________________________________________ insurance (hereinafter called Group Plan) for Client’s employees at a competitive rate from a reputable insurance company; and Whereas, Broker is a duly licensed insurance broker in the state of ________________________________________________ (name of state); and Whereas, Client desires to employ Broker, and Broker desires to be employed, as an agent to obtain such a Group Plan. Now, therefore, for and in consideration of the mutual covenants contained in this agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: 1. Employment of Broker A. Client employs Broker as its agent to obtain a Group Plan for Client’s employees at a competitive rate from a reputable insurance company. B. The terms Client desires Broker to obtain regarding Group Plan are as follows: (describe acceptable range of premiums, deductible, maximum coverage, etc.) _____________ ______________________________________________________________________________ _____________________________________________________________________________. C. Broker shall have the exclusive right to obtain this Group Plan for a period of (number) __________ days from the date of this Agreement. 2. Commission Client agrees that Broker shall be solely entitled to whatever commission the Group Plan carrier normally pays for this type of group plan. 3. Expenses of Broker Broker shall be responsible to pay for any out-of-pocket expenses he incurs in obtaining said Group Plan, including, but not limited to, travel, meals, and office supplies. 4. Covenant of Broker Broker covenants to use his best efforts and to act diligently in attempting to obtain the Group Plan. 5. Independent Contractor Status of Broker It is acknowledged and understood by Client and Broker that Broker is an independent contractor and shall not be considered Client’s agent for any purpose whatsoever other than procuring a satisfactory Group Plan, and Broker is not granted any right or authority to assume or create any obligation or liability or make any representation, warranty, or agreement, express or implied, on Client’s behalf or to bind Client to a third party in any manner whatsoever. 6. Damages on Breach of Agreement by Client Client and Broker acknowledge that it would be impractical or extremely difficult to fix the Broker’s actual damages in the case of a breach by Client of Paragraph 1-C, and, therefore, in the event of such a breach, Client must pay Broker the sum of $___________________ as liquidated damages, and not as a penalty for such a breach. 7. No Waiver The failure of either party to this Agreement to insist upon the performance of any of the terms and conditions of this Agreement, or the waiver of any breach of any of the terms and conditions of this Agreement, shall not be construed as subsequently waiving any such terms and conditions, but the same shall continue and remain in full force and effect as if no such forbearance or waiver had occurred. 8. Governing Law This Agreement shall be governed by, construed, and enforced in accordance with the laws of the State of ________________________________________. 9. Mandatory Arbitration Any dispute under this Agreement shall be required to be resolved by binding arbitration of the parties hereto. If the parties cannot agree on an arbitrator, each party shall select one arbitrator and both arbitrators shall then select a third. The third arbitrator so selected shall arbitrate said dispute. The arbitration shall be governed by the rules of the American Arbitration Association then in force and effect. 10. Entire Agreement This Agreement shall constitute the entire agreement between the parties and any prior understanding or representation of any kind preceding the date of this Agreement shall not be binding upon either party except to the extent incorporated in this Agreement. 17. Modification of Agreement Any modification of this Agreement or additional obligation assumed by either party in connection with this Agreement shall be binding only if placed in writing and signed by each party or an authorized representative of each party. 18. Assignment of Rights The rights of each party under this Agreement are personal to that party and may not be assigned or transferred to any other person, firm, corporation, or other entity without the prior, express, and written consent of the other party. 19. Counterparts This Agreement may be executed in any number of counterparts, each of which shall be deemed to be an original, but all of which together shall constitute but one and the same instrument. WITNESS our signatures as of the day and date first above stated. ____________________________________ (Name of Client) _______________________________________ By_________________________________ (Name of Broker) ____________________________________ (Name and Office in Corporation)