c o BIOGRAPHICAL INFORMATION FOR CONTRACT APPLICANT This form must sesompany all contac submited to tanner Life Insurance Company. Please prt or ype all information. ‘Section | - CONTRACT TYPE Please check only one. Contracts for: CI individual - complete setions J, I,1V end V. (Cindiviceal, bt “doing business 25" complete all sections. corporation - complete al sections. ‘Section If - INDIVIDUAL APPLICANT OR CORPORATE PRINCIPAL REQUIRED INFORMATION Social Security Number: Sec 0 Male O Female Ree ‘Name: a ——. JJ ao .m rrr Date of Bint: Email Ades: Tar Business Phone: FaxNo. _ - Business Nam _ Business Address. ieee ow == Home Address: a a ae Heme Phone: Web Site Address Iam an office ofthe below corperstion. ‘Tax ID Number: Corporate Name: ‘Corporate Fone: Conporate Fae Na: Corporate Address: pot pars a ‘Sie Nae Cr = Corporate E-mail Address: Primary Principal for Corporate Records: ‘Background information reported on page 2 should provide information forthe primary principal andthe corporation. ‘Additional Principals: _ (Office Manager or Primary Contzc: Phone Na: ‘Toll-Free Number for Client Call: ‘lease atch copy of your lenses) for your sat f residence and anyother states where you laa f do asiness with ‘Banner Please compete the second page ofthis form as wel. BK-10 (708) Paget ofIncomplete information will delay contracting. ‘Section TV - BACKGROUND INFORMATION REQUIRED FROM ALL APPLICAN’ Please provides detailed Inter ofexplanaton for any “yes" answers below. Iftisis «corporate application, the questions should be answered by the agency principal 1. Do you have any uncatinfed judgements, gerishments or lens against you? vs ONo 2 Are youin debi w any insurance ccmmpany? DYs ONo 33 Have you ever filed fer or hoon declared bankrupt or incolvent either personally orinbusiness? C1Yes_ C1No, 44 Have You ever been charged with convicted of or plead no contest to: ‘a any felony or misdemeanor? OY ONo |b any violation of ony state insurance regulations or statis? Dyes No any violation of federal or state soeulis or ivestment related regalatons? vs ONe 5. Areyou now orhave you ever been the sbjext of ay insarance or investneat related customer complaint, imestgation or proceeding? vs ONo 6 Have you ever had your contractor appointment terminated or refised by any insurance or financial services company? Yes ONo 7. Have you over hala license denied, revoked or suspended by any Seouritis andr State Fngurance Department? vs No 8. Have you used any otter names © aliases? Gye Ono Rema: CCament or previous employer: Are you now or have you ever heen contacted or otherwise associated with Banner Life? C) Yes C1 No or Wiliam Pena? T'Yes 2 No Yes, please provide details including agent # and agency name: _ ee Do you have Rirors and Omissions coverage? 1 Yes O No lfyou are a general agent, des your F&O policy cover sgentbroker scivity? Yes C1 No EROCarier a - Poliey Ne ffecive Date: Expization Date ‘Thereby certify tha al the information given to Banner Life by me it true and correct without ary omissions of any kind. Thereby authorize Banner Life to conduct a background investigation one, including 2 review of credit worthiness, now or at any tne. Tunderstand thet information may be obtained through writen comespondere, perearal or tslephone intorviowe with Fry, ‘ends, neighbors, busines associates or other aoquzntanoss, companies Lhave worked for or with whom [have been contracted, and any other persons or organizations contacted to supply such information. I also understand end acknowledge that ‘information received by Hamner Life may be shared withthe general agencies indicated below and herehy expeesly consent !o ‘he sharing of such information withthe eacral agencies indicated below. I further hereby cif tat if this application i approved, | willeomply wth ll the tems and conditvers ofthe Company's Agent/Agency Agreement, including, bu not limited 1 ees and condoning te Company's Privacy Ply. Apt ofthis orion sabe asa Print Name: Signatre: certify that I have reviewed this candidate's information and recommend him/her for contracting. Please sppoint ‘who reports to BDGA (if any): Name Code # ‘whoreports to BEGA (ifany}: Name Code ‘who reports to BMGA (if any): Name Code # ‘who reports 10 GA (required): Name _Tho Marketing Alliance inc Code #_Tee0000/Z890000 Signatwe of GA Date _ 1D Assignment of Commission form attached. (Assignee musi be appointed by Banner Tife.) K-10 00) Page? with comerission addendum _ma 170) Resear Souorars eck Manan 2850 (201) 276-800 (oon sseaees BANNER LIFE INSURANCE COMPANY ROCKVILLE, MARYLAND Agent/Broker Agreement Adoption Authorization In consideration of the covenants contained in the Banner Life Agent/Broker Agreement (AB-20 AB Agreement (07101), this ADOPTION AUTHORIZATION is exocutod as set forth below by and among Banner Life Insurance ‘Comparry, called the Company, and the General Agent and the Agent/Broker. All ofthe parties hereto acknowledge thal they have received and read the Banner Life Agent/Broker Agreement (AB.20 AB Agreement (07101). INWITNESS WHEREOF. the parties hereio have signed this ADOPTION AUTHORIZATION andayresitis effectveas ‘ofthe dete authorized by the Company, i, The Contract Date. AgentBroker Gonoral Agont “The Marketing Alliance inc Firm Name, W contracted Firm Name, f contracted sy y___ Ronald Verzone - Chairman Print Name & Tile Print Name & Tile ‘Signature Date Signature Date Banner Life insurance Company By: Joseph M. Suliven Chief Marketing Officer Sinature ‘AB.20 AB Adoption Authorization (104)