once the page loads, select “new user?” to register for … authorization please read this...

Contracting with Neishloss & Fleming, Inc. is now easier than ever! Neishloss & Fleming, Inc. offers the services of SureLC

for contracting with various Health, Life, and Senior carriers.

With the exception of a few carriers, you will be able to contract for multiple carriers in about eight minutes or less with

the click of a mouse. You can complete your agent profile and submit your complete contracting requests to Neishloss &

Fleming, Inc. without having to fill out a single piece of paper!

To begin contracting through SureLC, simply follow the link below to get started:

https://surelc.surancebay.com/sbweb/agency/283

Once the page loads, select “New User?” to register for SureLC

(NOTE: If you have already registered for SureLC and you are

adding a carrier to your profile, simply log in using the Login

and Password that you previously created).

A new page will reload that looks like this:

The only thing that you need to remember is to list

Neishloss & Fleming, Inc. on the Affiliation Line.

You will then enter all of your personal information

into the requested fields, click “Add Me” and

SureLC will pull your information from the NIPR

database. After the data transfer is complete, you

will be able to change/update any of the pre-

populated information as well as upload a copy of

your voided check, proof of E&O insurance,

Signature Page and N&F agent addendum (both

documents are provided in this pack immediately

following this page and must be attached to

SureLC).

If you do not have access to a scanner, please feel free to use the provided fax cover sheet and fax the forms (as well as

a copy of your voided check for EFT) to 412-561-6432 and we will email them to you in PDF format.

At the end of this pack you will find a SureLC FAQ containing additional information on the SureLC online contracting

process.

If you have any questions at all, give us a call at 800-562-7733. We look forward to working with you!

https://surelc.surancebay.com/sbweb/agency/283

By signing and electronically submitting this form, I am agreeing to contract for the carrier(s) listed above at the stated commission level with

the stated hierarchy.

Date:

I, , would like to be appointed for

Highmark MA through Neishloss & Fleming, Inc. My Commission level for this carrier is

Agent .

Please appoint me for:

Highmark Blue Cross Blue Shield

Should you have any questions, please call me at .

Sincerely,

Agent Name

Carrier Name

Commission Level

Phone Number

Agent Signature

Highmark Blue Shield

Signature Authorization

PLEASE READ THIS AUTHORIZATION, SIGN IN THE BOX BELOW AND

SUBMIT THIS FORM BY FOLLOWING THE INSTRUCTIONS PROVIDED

ON THE COVER PAGE.

I, ____________________________________, hereby authorize

SuranceBay, LLC and its general agency customers (the “Authorized

Parties”) to affix or append a copy of my signature, as set forth below,

to any and all required signature fields on forms and agreements of

any insurance carrier (a “Carrier”) designated by me through the

SureLC software or through any other means, including without

limitation, by e-mail or orally. The Authorized Parties shall be

permitted to complete and submit all such forms and agreements on

my behalf for the purpose of becoming authorized to sell Carrier

insurance products. I hereby release, indemnify and hold harmless the

Authorized Parties against any and all claims, demands, losses,

damages, and causes of action, including expenses, costs and

reasonable attorneys' fees which they may sustain or incur as a result

of carrying out the authority granted hereunder.

By my signature below, I certify that the information I have submitted

to the Authorized Parties is correct to the best of my knowledge and

acknowledge that I have read and reviewed the forms and agreements

which the Authorized Parties have been authorized to affix my

signature. I agree to indemnify and hold any third party harmless from

and against any and all claims, demands, losses, damages, and causes

of action, including expenses, costs and reasonable attorneys' fees

which such third party may incur as a result of its reliance on any form

or agreement bearing my signature pursuant to this authorization.

Please sign in the center of the box below. Please use BLACK ink.

PRODUCERIDXXX

TO: FROM:

Contracting

COMPANY: DATE:

FAX NUMBER: TOTAL NO. OF PAGES INCLUDING COVER:

412-561-6432

RE:

Supporting Documentation for SureLC

URGENT FOR REVIEW PLEASE COMMENT PLEASE REPLY PLEASE RECYCLE

Please find attached my information to complete the SureLC contracting process. I do not have access to a scanner to attach the documents in PDF format. I have included the following documents:

N&F Contracting Addendum SureLC Signature Page Proof of E&O Voided Check Supporting Documents for Background Questions

Below you will find my contact information in case all documents have not been received as well as to return the forms: Agent Name: Phone Number: Email Address:

2 2 7 5 S W A L L O W H I L L R O A D , B U I L D I N G 3 0 0 , T H E B O U R S E , P I T T S B U R G H , P A 1 5 2 2 0

V O I C E ( 8 0 0 ) 5 6 2 - 7 7 3 3 F A X ( 4 1 2 ) 5 6 1 - 6 4 3 2 W W W . N E I S H L O S S . C O M

SureLC FAQ

Do I have to install software onto my computer to use SureLC? No, you do not have to install software to enjoy the benefits of SureLC. You can access SureLC through a web link on the Neishloss & Fleming, Inc. website.

How long does it take to set up my SureLC agent profile? You can be set up in SureLC and ready to submit contracting through SureLC in about 8 minutes.

Will I be required to complete a new agent profile each time I log into SureLC? No! After you complete your initial agent profile in SureLC, your information will be saved for the next time you want to contract for a carrier.

Can I select and submit contracting for multiple carriers at one time using SureLC? You will be able to submit multiple contracts while logged in to SureLC; however you cannot select multiple carrier contracts at one time because SureLC does ask additional questions based upon the carrier selected.

How do I electronically sign the contracting forms in SureLC? You have two options for loading your signature into the SureLC website.

The first option is to physically sign the Agent Signature document, scan it into your computer, and manually attach the document. The second option is to use your mouse to create an e-signature in the SureLC database. When completing the Agent Profile section of your profile, you will have the option to select the method you wish to use.

How do I get a copy of my voided check, E&O, and Signature Page into SureLC? You have a few options of uploading this information into the SureLC database. The first option is to scan and upload a copy of the documents and manually attach them to SureLC. The second option (which is a new feature to SureLC) is to use your computer’s webcam and take a picture of the documents. The webcam picture will automatically load the documents into the documents tab of SureLC.

If appointment fees are required for a carrier, am I able to pay them through SureLC via credit card? Unfortunately, if an appointment fee is required, you will need to send a check to Neishloss & Fleming, Inc. via USPS as SureLC is not set up to accept fee payment electronically. The fees can be mailed to:

Neishloss & Fleming, Inc. Attn: Administrative Division 2275 Swallow Hill Rd. Building 300 Pittsburgh, PA 15220

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AGENT'S CONTRACT

THIS CONTRACT, executed this the______day of ______________, 20_,

between NEISHLOSS & FLEMING, INC., of Pittsburgh, Pennsylvania, herein called

"N&F", and _______________________of ________________________,hereinafter called

the "AGENT", WHEREIN IT IS MUTUALLY AGREED AS FOLLOWS:

1. APPOINTMENT OF AGENT

N&F appoints the above named agent for the sale of certain applications for

policies of life and health insurance of Companies named in the attached

commission schedule. Agent is responsible for obtaining and maintaining proper

licensing with said Companies.

2. INDEPENDENT CONTRACTOR

Nothing contained herein shall be construed as creating the relationship of

employer and employee between N&F and the agent. The agent shall be free to

exercise his own judgement as to the time, place and manner in which he may

perform the services authorized under this agreement.

3. LIMITATIONS OF AUTHORITY AND DUTIES

The agent is not authorized and is expressly prohibited on behalf of N&F or

any Company named herein to incur any indebtedness or liability to make, modify,

discharge or waive any of the terms of any policy or contract, to extend the

time of any payments due or promise to pay a claim. N&F may from time to time

prescribe rules and regulations with respect to the conduct of the business

covered herein. The agent shall conform to and observe such rules and

regulations as established and amended by N&F.

4.COMPENSATION

As compensation in full for the performance of services, the agent, as

authorized in the contract, N&F will pay commissions as set forth in the

attached schedule of commissions. The rate of commissions may be changed,

altered or amended from time to time by N&F, and effective upon any business

written by the agent subsequent to the effective date of the change.

The Agent's commissions shall consist of the following:

(a) FIRST YEAR COMMISSIONS: Those percentages of the premium for the first

policy year as shown in the schedule of commissions.

(b) RENEWAL COMMISSIONS: Those percentages as shown in the schedule of

commissions.

(c) SERVICE FEE: A service fee shall be payable as shown in the schedule of

commissions if the agent is eligible. The agent shall be able to receive a

service fee only if at the time of payment of renewal premiums he (1) is

properly licensed and appointed by the Companies named in the schedule of

commissions, (2) is actively engaged with N&F as an agent, and (3) is servicing

all his business in a manner satisfactory to N&F. (4) Service fees will not be

paid after the death of the agent. (5) The agent maintains in-force annualized

individual plan premium of no less than fifty thousand dollars.

5. VESTED COMMISSIONS:

The vesting of commissions shall in no way limit or otherwise affect the

right of N&F or any Company to service the business on which vested commissions

are paid.

VESTED COMMISSIONS AFTER TERMINATION: this contract shall be terminated by the

death of the agent and all renewal commissions payable as provided herein shall

be vested and payable to the surviving spouse of the agent. If there is no

surviving spouse or is the spouse dies prior to receiving all renewal

commissions payable hereunder, then such renewal commissions shall be paid to

the Executors or Administrators of the agent's estate. If the contract should be

terminated by either party, or due to the death of the agent, personal

commissions will be payable as follows:

(a) The personal first year commissions on any policies in accordance with

the schedule of commissions will be vested and payable in accordance with said

schedule.

(b) The personal renewal commissions on any policies in accordance with the

schedule of commissions will be vested and payable in accordance with said

schedule, subject to: (1) No further commissions of any type will be payable

should any of the following conditions occur: (a) the agent commits or attempts

to commit any illegal, fraudulent or dishonest act; (b) the agent induces or

attempts to induce any policyholder in force with N&F and its Companies to

discontinue premium payments on any of their policies; (c) the agent induces or

attempts to induce any N&F agent, broker or employee to sever his relations

with N&F.

(c) If this contract is terminated for cause, as defined in the contract, no

further commissions, service fees or other compensation will be payable.

6. ASSIGNMENTS

No assignment of this contract or any compensation payable hereunder shall be

valid or binding on N&F unless authorized in advance by the President, a Vice

President, or Secretary. Any assignment so authorized shall be subject to any

and all indebtedness of the agent then existing or thereafter occurring.

7. VENUE STATED

Any suit between N&F and the agent growing out of any transaction arising

from, based on or in any way connected with this agreement shall be instituted

and tried only in Allegheny County, Pennsylvania. All of the terms, provisions

and conditions of this contract shall be construed according to the laws of

Pennsylvania.

8. INDEBTEDNESS

N&F shall have a first lien on all commissions payable under this agreement. For

purposes of this agreement, indebtedness shall include cash advances made by N&F

to the agent. The agent shall be responsible for and hereby agrees to the

repayment to N&F of such advances.

9. ACCOUNT STATED

The agent hereby agrees that the ledger accounts of N&F shall be competent and

sufficient prima facie evidence of the state of accounts between the parties

thereto. The failure of the agent to object in writing to specific items of the

statement of accounts furnished by N&F to the agent within sixty calendar days

from the date such statement of accounts is furnished, shall render such

accounts correct between the parties.

10. DEFINITIONS

Where the word "person" or the personal pronouns "he, him or his" are used in

this agreement, they are intended to be construed as both male and female, and

they are intended to mean the agent, whether the agent is an individual, a

partnership or corporation.

11. MODIFICATION

This agreement cannot be changed by any verbal promise or statement by any of

the parties thereto, and no written modification or change shall bind N&F unless

it is signed by the President, a Vice President or Secretary of the Company and

expresses an intention to modify or change this agreement.

12. NO WAIVER

No forbearance or neglect by N&F to enforce any term, condition or provision

of this contract shall be construed as a waiver of any of its rights hereunder.

13. TERMINATION

In the event the agent fails to comply with any of the provisions contained

herein, this contract may be immediately terminated by N&F by written notice to

the agent, such notice of termination to be effective on the date specified

therein. Forbearance or neglect on the part of N&F to insist upon the

performance of any part of this contract or to declare a forfeiture or

termination shall not be deemed to constitute a waiver of such rights and

privileges.

This contract shall terminate upon the death of the agent or upon his

becoming totally and permanently disabled. This contract may be terminated at

any time by either party desiring to terminate it giving the other party thirty

days written notice of termination, which notice shall be delivered either

personally or mailed to the last known address of the other party.

Upon termination of this contract, the agent shall immediately pay in cash to

N&F all sums then due.

IN WITNESS THEREOF, this contract is executed in duplicate this ________day of

________________, 20___, and when approved by an authorized officer of N&F,

shall be effective for all purposes as of the aforesaid date.

NEISHLOSS & FLEMING, INC.

______________________________ By__________________________

Agent's Name (Print) President or Secretary

______________________________ ___________________________

Agent Signature Agent S.S.#

2015 Highmark Medicare Advantage Commission

Agent

Please note: Highmark will forward compensation once the policy appears on the CMS report. Commission will not be paid prior to the policy effective date. Renewal amounts follow CMS’ designated compensation level from the year policy is written and are paid

annually on a calendar basis. Full charge back will occur if the member dis-enrolls less than 90 days after enrollment. Partial charge back will occur on a pro-rata monthly basis tying back to the effective date of the policy.

Medicare Advantage (Freedom Blue PPO & Security Blue HMO)

Initial Payment, new to MAYear 1

Renewal PaymentYears 2 - 10

$ 461 $ 230

Medicare Advantage (Community Blue HMO)



$ 461 $ 230

Medicare Prescription Drug Plans (Blue Rx)



$ 44.80 $ 22.40

MEDIGAP Blue

Applicant’sAttained Age

Initial PaymentYears 1-6

Renewal PaymentYears 7-10

Renewal PaymentYears 11+

under 65 & over80

$ 174.40paid monthly $ 14.53

$ 69.60paid monthly $ 5.80


65-79 $ 348.80paid monthly $ 29.07

$ 139.20paid monthly $ 11.60


Agent Signature: Date:

2275 Swallow Hill Road Building 300 The Bourse Pittsburgh, PA 15220 Phone 800.562.7733 Fax 412-561-3038 www.neishloss.com

Please use this form to designate commission payments from Neishloss & Fleming, Inc.

Agent Name: _______________________________________________________

Agency: ____________________________________________________________

Address:

___________________________________________________________________

___________________________________________________________________

City: _______________________________ State: __________ Zip: ____________

Tax ID: _____________________________________________________________

Comments/Instructions:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

2275 Swallow Hill Road Building 300 Pittsburgh, PA 15220

800-562-7733

[email protected] www.neishloss.com

Commission Direct Deposit Authorization

Instructions: Please complete Parts A through C, attach a voided check, and return to address above. Please Print.

Part A: Bank Account Holder Personal Information

Name / Payee:

Street Address:

City: State: Zip:

Phone Number: E-mail Address:

Part B: Bank Account Information

Action (please indicate):

□ Start Direct Deposit □ Change Account Information □ Stop Direct Deposit

Account Type (please indicate):

□ Checking □ Savings

Routing Number: □□□□□□□□□

Account Number: □□□□□□□□□□□□□□□□□□

Part C: Bank Account Holder(s) Signature(s)

I (we) give Neishloss & Fleming permission to automatically make commission payments to my (our) bank account. This authorization will remain in force unless I (we) cancel it or my (our) bank account is closed.

Signature: Date:

Joint Signature: Date:

Printed Name(s): /