CBIZ / ZURICH LIFE Fill-Able Contracting/Appointment Forms

When do I submit CBIZ/ZURICH LIFE Appointment Paperwork? • Appointment paperwork and new business

application can be submitted concurrently except in the states listed below.

Where do I submit CBIZ/ZURICH LIFE Appointment requirements? • Please forward all completed forms directly to

CBIZ Life Insurance Solutions, Inc. o Fax: 858.444.3157 OR o Email: srlicensing@cbiz.com

Who should I contact for contracting and/or appointment inquiries? • Please contact our Producer Services

Department

Email: srlicensing@cbiz.com Phone: 800.422.7536 Fax: 858.444.3157 Mail: 10616 Scripps Summit Court, Suite 210

San Diego, CA 92131

What requirements must be submitted for a CBIZ/ZURICH LIFE Appointment? • All pages of ZURICH LIFE Producer

Appointment Application

o Application for Contracting & Appointment

o Broker Agreement [Form# IFA-1001]

o Commission Direct Deposit Form [Optional]

o Assignment of Commission Form [complete only if applicable]

• Request for Taxpayer ID# [W-9]

• Current Resident Life License and/or License in the state of sale.

• Proof of Current Errors & Omissions or Certificate of Liability

Proof of Anti-Money Laundering (AML) training completion will be required to provide upon request by the carrier

 

CBIZ LIFE INSURANCE SOLUTIONS, INC.

 Producer Services Department

10616 Scripps Summit Ct., Suite 210 ● San Diego, CA 92131 Phone: 800.422.7536 ● Fax: 858.444.3157

Email: srlicensing@cbiz.com  

IFA-5000 (03/10) Page 1 of 4

With each of the Zurich® life insurance companies (each a “Company” and collectively the “Companies”) listed below:

Kemper Investors Life Insurance Company. Schaumberg, IL

New Business Complete if you are submitting a new business application with this appointment / contracting application.

________________________________________________ __________________________________________ Proposed Insured’s Name Policy Number (if applicable)

________________________________________________ ____________________________ ___________Proposed Insured’s SSN Application Sign Date State

A. Personal Information (Required of all applicants)

________________________________________________ ____________________________ ___________First Name Last Name Middle Initial

______________________________________ ____________________________ Male FemaleBirth Date SSN

________________________________________________ _____________________ ________ _________Residence Street Address City State Zip Code

_______________________ How long have you lived at this residence? _______________________________ Phone If less than two years in your current residence please list your former address.

________________________________________________ _____________________ ________ _________Former Residence Street Address City State Zip Code

How long did you lived at your former residence? __________________________________________________

______________________________________________ ____________________ ________ _________Business Street Address City State Zip Code

______________________ ______________________ _________________________________________Phone Fax E-mail Address Application Type: Individual OR Corporate / Partnership

If applying for a corporate or partnership appointment and contract, please also complete Section D of this application.

Application for Contracting and Appointment

Application for Contracting and Appointment (continued)

IFA-5000 (03/10) Page 2 of 4

B. Errors and Omissions InformationRequired of all applicants. Please attach a copy of your policy’s specifications page.

________________________________________________ __________________________________________ E&O Carrier Name Name of Insured

________________________________________________ ____________________________ ___________Policy Number Expiration date State

Coverage amounts: Per Act _______________________ Aggregate ________________________________

Have you ever filed a claim? Yes No If yes, please attach an explanation.

C. Background Information Required of all applicants. If you answer ‘yes’ to any questions, you must attach an explanation with supporting information and documents.

1. Have you ever had an insurance and/or securities license or registration under another name?

If yes, please provide that name: _______________________________________________

2. With the exception of routine traffic violations, have you ever been charged with, convicted of or

plead guilty or no contest to a misdemeanor or felony?

3. Within the past 10 years, have you or any firm in which you were a partner, officer or director:

a. Ever initiated bankruptcy proceedings or declared bankruptcy?

b. Ever defaulted on a promissory note or other debt including consumer or credit cards?

4. Has any insurance carrier cancelled your contract or appointment for any reason other than lack

of production?

5. Have you ever had a complaint filed against you that resulted in a fine, penalty, censure, cease

and desist order consent order or disciplinary action?

6. Have you ever been named as a defendant or codefendant in a lawsuit initiated by an

insurance company?

7. Have you ever been discharged or permitted to resign from any position because you were accused of:

a. Violating insurance or investment statues, regulations, rules or industry standards of conduct?

b. Fraud or the wrongful taking of property?

8. Do you currently owe money to any insurance company?

9. Within the past 10 years:

a. Has a bonding company ever denied, paid out on, or revoked a surety or fidelity bond for you?

b. Has any E&O carrier denied, paid claims on, or canceled your coverage?

10. Are you currently a registered representative with FINRA?

If yes, please provide CRD number __________________________________________

11. Has your license ever been suspended or revoked or terminated?

12. Have you completed Anti-Money Laundering (AML) Training?

If yes, provide copy of the AML training certificate.

Yes No

Yes No

Yes No Yes No

Yes No

Yes No

Yes No

Yes No Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

D. Corporate / Partnership Data Required of all corporate or partnership applicants.

________________________________________________ __________________________________________ Name of Corporation or Partnership Tax ID Number

____________________________________________________________ ______________________________ Name of licensed corporate officer Phone

________________________________________________ _____________________ ________ _________Address City State Zip Code

State of incorporation: ____________________________

Does your resident state permit corporations and/or partnerships to be licensed? Yes No

Pay commissions to the: Firm Licensed Associate

If commissions are to be paid to an associate, complete Assignment Form.

E. Licensing and State Appointment RequestRequired of all corporate or partnership applicants. Attach copies of licenses for all requested state appointments. Attach a check made payable to Zurich for appropriate nonresident appointments fees.

Contracted as: Individual Corporate / Partnership Resident state: ____________ Please process the appointment(s) request for the following states:

_________ _________ _________ _________ _________ _________

F. Line of Business Information Required of all applicants. Please provide information for last 12 months.

Please indicate the percentage of your total production mix:

Life Insurance ______ %Annuities ______ %Health Insurance ______ %COLI / BOLI ______ %Other ______ %

Please indicate the total paid life insurance target premium you produced in the past 12 months. $ __________ Top 3 life carriers by production (last 12 months):

1. ________________________________________________

2. ________________________________________________

3. ________________________________________________

Please indicate the percentage of your total life insurance sales by product type:

Universal Life ______ %Index UL ______ %Variable ______ %Whole Life ______ %Term ______ %

IFA-5000 (03/10) Page 3 of 4

Application for Contracting and Appointment (continued)

G. Technology Information Please indicate the Agency Management System you utilize.

AgencyWorks Oracle SmartOffice Other: _____________________

H. Key Agency PersonnelPlease provide contact information for the following Key Agency Personnel

____________________________________ ___________________ _________________________________ Illustrations Name Phone E-mail

____________________________________ ___________________ _________________________________Underwriting Name Phone E-mail

____________________________________ ___________________ _________________________________Commissions Name Phone E-mail

____________________________________ ___________________ _________________________________Policy Service Name Phone E-mail

I. Conditions and Agreements

By signing this Application, I acknowledge and represent that:

•AllinformationfurnishedinthisApplicationistrue,correctandcomplete. •IunderstandthatnoCompanyisobligatedtoapprovethisApplication.Ireleaseandwillnotholdany

Company liable for not appointing or contracting with me.

• I agree to comply with all state laws with regard to solicitation of business prior to appointment and contracting.

• I authorize any person or entity that may have knowledge of my employment, financial, criminal or other history to release such information to any Company in connection with this Application. A photocopy of this authorization will be as valid as the original, regardless of the date it is signed.

•I also acknowledge by my signature below that I authorize the Company, now or in the future, to obtain a consumer or investigative consumer report on me, and that I have received from the Company all disclosures required by the Fair Credit Reporting Act. I understand that I will be notified in writing by a Company that takes adverse action based on any information in a consumer or investigative consumer report.

• I authorize the Company to report information about earnings and debit balances to any credit bureau or similar organization.

• I agree to maintain the level of Errors and Omissions (E&O) coverage as required by the Company.

__________________________________________________________________________________________ Print Applicant Name (Corporate/Agency Officer if applicable)

__________________________________________________________ ______________________________ Applicant Signature (Corporate/Agency Officer if applicable) Date

IFA-5000 (03/10) Page 4 of 4

Application for Contracting and Appointment (continued)

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.

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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 CertificationUnder 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 InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Purpose of FormA 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)

_______________________________________________ _____________________________________________ Name of BGA/Broker Date

_______________________________________________ _____________________________________________ Business Phone Fax Number

_______________________________________________ _____________________________________________ E-mail Address SSN/TIN

This Account is (check one): Checking Account Savings Account

_____________________________________ ____________________ _________________________________ Account Name 9 Digit ABA Number Account Number

_______________________________________________ ____________________ _________ ____________ Bank Name City State Zip Code

To assist in sending a confirmation that your direct deposit request has been processed, please provide your business address information.

______________________________________________________________________________________________Name

______________________________________________________________________________________________Street/PO Box

________________________ ______________________ City, State Zip Code

Note: Please do not assume that your compensation will be deposited into your account because you have EFT/direct deposit. Always check your commission statement to determine the amount deposited into your account.Allow at least 3 business days for EFT/direct deposit to be processed into your account. Questions regarding this information can be directed to the Commission Department 877-678-7534, option 2.

___________________________________________________________ _________________________________ Signature Title

Mail to: Zurich Attention: Commission Department 7045 College Boulevard, Overland Park, KS 66211 (attach a voided or cancelled check from your banking institution)

Or Fax to: Zurich, Commission Department 913-664-4713

You are responsible for ensuring all information is correct.

In order to initiate the EFT direct deposit of compensation, the following information must be completed. Please print or type .

Page 1 of 1

Commission EFT Direct Deposit Request

Zurich American Life Insurance CompanyAttention: Licensing and Commissions 7045 College Boulevard, Overland Park, Kansas 66211-1523

Phone: 877.678.7534, Option 2 Fax: 913.664.4713