Gerber Life Insurance Application

Gerber Life Insurance Contracting Application

To become contracted with Gerber Life, complete the attached application and sign where indicated.

Fax or email your completed application along with copies of all insurance licenses for the states in which you will be soliciting business.

If you require any assistance, please call us at 1-800-770-0492.

Please fax or email pages back to us that you have written on. Include your state insurance license(s) and void check.

Available in AL, AR, AZ, CA, CO, DE, FL, GA, IA, ID, IL, IN, KS, KY, LA, MD, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, SC, SD, TN, TX, UT, VA, WA, WI, WV and WY.

Void check must have pre-printed bank information - otherwise letter from the bank.

Please go to http://www.hellosign.com to electronically fill out the contract. Hellosign is free.

Please join our Conference Call Monday thru Thursday Noon ET

Dial 424-203-8405 - id: 464305

2014 Commission Schedule Click Here

For those contracted with another IMO click here

Sincerely,

Agent Services (www.naaip.org/agents)

Tel: 1-800-770-0492

Fax: 1-866-436-1640

Email: david (at) naaip.org

Contracting 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

Section 1 - Producer Information (Required)

Name: SSN: DOB:

Home Address: City: State: Zip Code:

Business Address: City: State: Zip Code:

Home Phone: Business Phone: email Address:

Master General Agency (if applicable):

Background Information (Required - Must be answered)

Yes No Have you ever been fined, suspended, placed on probation, paid administrative costs, entered into a consent order, been issued a restricted license or otherwise been disciplined or reprimanded, or are you currently under investigation by any insurance department, FINRA (formerly known as NASD), SEC or any other regulatory authority?

Yes No Have you ever been convicted or plead guilty or nolo contendere (no contest), served any probation, paid any fines or court costs, had charges dismissed through any type of first offender or deferred adjudication or suspended sentence procedure, or are any charges currently pending against the applicant for any offense other than a minor traffic violation?

PLEASE PROVIDE A WRITTEN STATEMENT disclosing the offense, the disposition and applicable supporting documentation (court documents, insurance department documents etc.) for any question(s) to which you responded "YES". Failure to answer "yes", when appropriate, may result in denial of your request to be contracted.

Contracting Selection (Required - Select only one)

General Agent Agreement and Confidentiality and Privacy Amendment (BMO02G.003)

Special Agent Agreement and Confidentiality and Privacy Amendment (BMO03G.003)

Retain a copy of the agreement for your files. A copy will not be returned to you.

Direct Deposit Information (Complete if you are electing direct deposit - not applicable for Special Agents)

Financial Institution:

Routing Number: Account Number: Account Type Checking Savings

This is not an assignment of commissions. Form 1099 will be issued to the commission owner.

Designation of Beneficiary (if applicable)

Name: Relationship:

Home Address:

SSN: or TIN: DOB: Phone Number:

W-9 Information

Taxpayer Identification Number (SSN)

Social Security Number

Certification

Sign Here: Date:

****Please proceed to Section 3****

Section 2 - Business Information (Only complete this section if contracting as an Incorporated Entity, Partnership or LLC)

Name: TIN:

Address: City: State: Zip Code:

Phone: email Address:

Principal Officer:

Master General Agency (if applicable):

Contracting Selection (Required - Select only one)

General Agent Agreement and Confidentiality and Privacy Amendment (BMO02G.003)

Retain a copy of the agreement for your files. A copy will not be returned to you.

Direct Deposit Information (Complete if you are electing direct deposit)

Financial Institution:

Routing Number: Account Number: Account Type Checking Savings

This is not an assignment of commissions. Form 1099 will be issued to the commission owner.

W-9 Information

Employer Identification Number

Certification

Sign Here: Date:

Section 3 - Contract Signature, Certification and Direct Deposit Authorization

By signing below: (a) you agree to be bound by the terms and conditions of the Agreement(s) selected, (b) you certify that the information that you have provided is true and correct and you agree that you will report immediately any change in the information, in any manner, that you have provided, and (c) if you have completed the Direct Deposit section(s) you authorize Gerber Life Insurance Company ("Company") and its affiliates to electronically credit the bank account and, if necessary, to electronically debit the bank account to correct erroneous credits.

Individual Fair Credit Reporting Act Authorization

Gerber Life Insurance Company and its affiliates with which you intend to contract (together, “Gerber Life”) will obtain and use consumer reports for the purpose of serving as a factor in establishing your eligibility for contracting as an insurance producer.

We will obtain these reports from:

First Advantage Corporation
100 Carillon Parkway, Suite 100
St. Petersburg, FL 33716
(800) 321-4473

If you are not a California resident or are not requesting a California appointment along with your request to contract with Gerber Life, we may also obtain a consumer report from other sources.

“Consumer report” means a written, oral or other communication of any information by a consumer reporting agency bearing on your creditworthiness, credit standing, credit capacity, character, general reputation, personal characteristics or mode of living which will be used by Gerber Life, in whole or in part for the purpose of serving as a factor in establishing your eligibility to be contracted as an insurance producer.

This means a credit report, criminal report and report of insurance department regulatory actions will be obtained and reviewed as part of a background investigation in order to determine your eligibility to be contracted and appointed.

CANDIDATE'S STATEMENT – READ CAREFULLY

Gerber Life is hereby authorized to obtain and use a consumer report of my criminal record history, insurance department history and credit history through any consumer reporting agency.

AUTHORIZATION

I authorize any consumer reporting agency, insurance department, law enforcement agency, the Financial Industry Regulatory Authority, The Securities and Exchange Commission or any other person or organization having any consumer report records, data or information concerning my credit history, public record information, insurance license, regulatory action history or criminal record history to furnish such consumer report records, data and information to Gerber Life.

I understand that if contracted, this authorization will remain valid as long as I am contracted with Gerber Life.

A photocopy of this authorization shall be considered as effective as the original.

Selection of Mode of Advance

Please Select one mode of advance from the choices below and acknowledge your choice by initialing under your selection. All choices are for advance of commission upon the issuance of an eligible Product.

Six-Month (QK4) Nine-Month (QK5) Twelve-Month (QK6)