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eContracting Registration
Call NAAIP Agent Services before filling out PDF. Call Now: 1‐800‐770‐0492 eContracting Login MedAmerica Insurance Company Contracting Application Highest Commissions – Guaranteed! Highest commissions ‐ Contracting ‐ MedAmerica. Call NAAIP direct at 1‐800‐770‐0492 for appointment. Alternatively, 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. Please fax or email pages back to us that you have written on. Include your state insurance license(s), declaration page of your E and O and void check. Void check must have pre‐printed bank information ‐ otherwise letter from the bank. Agents will be Contracted at the Highest Commission Level.
Call NAAIP Agent Services before filling out this PDF for a higher
contract.
1-800-770-0492
Please go to http://www.hellosign.com to electronically fill out the contract. Hellosign is free. Go to www.naaip.org to learn about our free agent websites with 3 quote engines
and our free lead program. Monday thru Thursday conference call at Noon ET.
2014 Commission Schedule Click Here
Sincerely, Agent Services (www.naaip.org) Tel: 1‐800‐770‐0492 Fax: 1‐866‐436‐1640 Email: david (at) naaip.org PRODUCER PROFILE
You may not solicit applications on Our behalf until your appointment has been processed according to state insurance department
regulations. Applications dated prior to this agreement and/or appointment effective date will be returned.
I. PRODUCER INFORMATION:
(ALL FIELDS are REQUIRED unless otherwise indicated.)
Producer Name (First, MI, Last)
Social Security Number
Legal Residence Street Address (PO Box Not Adequate-Must Provide Street)
Mailing/Delivery Street Address (if different)
City
City
(
State
)
(
Business Phone (Required)
Zip
)
(
Business Fax (Optional)
_______/_________/________
MM /
DD / YYYY
Male
Date of Birth
National Producer No.-NPN#
State
)
(
Home Phone (Optional)
Zip
)
Mobile Phone (Optional)
Female
Sex
Email (Required)
Your Agency Name (if you are the Principal of the Agency and also submitting Agency Profile)
II. ERRORS AND OMISSIONS – Copy of E/O required that lists you as covered under the policy.
Carrier Name
III. PRODUCER’S STATEMENTS (Check Yes or No)
Agency Tax ID (if applicable)
_______/_________/________
MM /
DD / YYYY
Expiration Date
Policy Number
Yes
No
1. Have you ever been convicted or pled nolo contender for any offense other than minor traffic violations?
2. Have you ever filed for bankruptcy, been a party in an insolvency proceeding or been a party to a tax lien?
3. Has your insurance license ever been fined, suspended, placed on probation, or is currently under investigation?
4. Are you now, or have you ever been, in debt to any insurance agency or carrier?
If your answer is “YES” to any of the above, please provide details on a separate sheet of paper and attach
IV. FAIR CREDIT REPORTING ACT NOTICE:
You are hereby notified that a background investigation and license verification will be completed on You prior to Your appointment with Us. You
authorize a release of written and verbal information about Yourself that may contain facts about Your background, general reputation and license to
solicit insurance. You have the right to make a written request for information on the Reporting Agency as well as the nature and scope of the
investigation. Furthermore, You have the right to (a) be told if the information in the investigative report negatively impacts Your application; (b) contact
the Reporting Agency for full disclosure of the information contained in the investigative report; (c) dispute inaccurate information with the Reporting
Agency. You can request a copy of the FCRA by contacting the Federal Trade Commission, Bureau of Consumer Protection - FCRA, Washington, DC
20580.
V. RESIDENT STATE APPOINTMENT REQUEST AND REQUIREMENTS---Check the ONE State you are Licensed as a RESIDENT AGENT—
All Producers are REQUIRED to provide the Resident State License and all Resident State Training Required.
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
VI. NON-RESIDENT STATE APPOINTMENT REQUEST AND REQUIREMENTSCheck All States You are Requesting a Non-Resident Appointment in and attach copies of Non-Resident License(s).
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
KY
LA
ME
MD
ND
OH
OK
OR
MA
PA
MI
MN
MS
MO
MT
NE
NV
RI
SC
SD
TN
TX
UT
VT
1
NH
VA
NY
NC
WI
WY
IA
KS
NJ
NM
NY
NC
WA
WV
WI
WY
LTC681-MA/MANY/MAFL-Producer Profile-9/2011
PRODUCER PROFILE (continued)
VII. New Business
Have you solicited an application on MedAmerica’s Behalf?
If Yes to the above question: Please provide the date the
application was signed by the applicant and what state.
Yes
No
_______/_________/________
MM
/
DD / YYYY
Application Sign Date
State of Solicitation
VIII. Producer Signature and Corporate Code of Business Conduct Acknowledgement
I certify that all of the information provided above is true and accurate.
I acknowledge that I have received The Lifetime Companies (the “Corporation”) Code of Business Conduct. I have read the Code and
understand its purpose. I understand that the Code applies to me and have abided by the Code, and will abide by the Code, in soliciting any
applications on behalf of the Corporation. I understand that I have a duty to report any violations of the Code and that if I fail to report a
violation of any provision of the Code that I may face termination of my contract to represent the Corporation.
X
Producer Signature
Date
ROUTING FORM (LTC685-RTE-9/2011) IS REQUIRED WITH THIS DOCUMENT
2
LTC681-MA/MANY/MAFL-Producer Profile-9/2011
AGENCY PROFILE
The Principal must complete this form for ANY AGENCY receiving Commission Payment.
Principal must also complete a Producer Profile.
I. AGENCY INFORMATION:
(ALL FIELDS are Required unless otherwise indicated.)
Agency Name (Legal Name as filed with IRS-W-9 Required)
Agency Tax ID
(as used to file Taxes with IRS)
Legal Business Address (PO Box Not Adequate-Must Provide Street)
Mailing/Delivery Street Address (if different)
City
(
State
)
(
Business Phone (Required)
Zip
City
State
Agency National Producer#-NPN#
Zip
)
Business Fax (Required)
Email (Required)
Print Name of Principal(s) of the Agency
Sole Proprietor
Partnership
LLC
C-Corp
S-Corp (Copy of Agency Licensed is Required)
Type of Business
II. ERRORS AND OMISSIONS – Copy of E/O required listing Agency as Covered
Carrier Name
III. AGENCY STATEMENTS (Check Yes or No)
_______/_________/________
MM /
DD / YYYY
Expiration Date
Policy Number
Yes
No
1. Has the Agency ever filed for bankruptcy, been a party in an insolvency proceeding or been a party to a tax lien?
2. Has the Agency’s insurance license or business license ever been fined, suspended, or currently under investigation?
3. Has the Agency now, or has the Agency ever been, in debt to any insurance agency or carrier?
If your answer is “YES” to any of the above, please provide details on a separate sheet of paper and attach
IV. FAIR CREDIT REPORTING ACT NOTICE:
You are hereby notified that a license verification and credit check may be completed on the Agency prior to approval to represent MedAmerica Insurance
Companies. The principal, by signature below, authorizes a release of written and verbal information about the Agency that may contain facts about the
Agency, general reputation and license to solicit insurance. You have the right to make a written request for information on the Reporting Agency as well
as the nature and scope of the investigation. Furthermore, You have the right to (a) be told if the information in the investigative report negatively impacts
Your application; (b) contact the Reporting Agency for full disclosure of the information contained in the investigative report; (c) dispute inaccurate
information with the Reporting Agency. You can request a copy of the FCRA by contacting the Federal Trade Commission, Bureau of Consumer
Protection - FCRA, Washington, DC 20580.
V. RESIDENT STATE APPOINTMENT REQUEST AND REQUIREMENTS
Check the ONE State you are Licensed as a RESIDENT AGENCY and attach Agency Resident License
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
VI. NON-RESIDENT STATE APPOINTMENT REQUEST AND REQUIREMENTSCheck All States You are Requesting a Non-Resident Appointment in and attach Agency Non-Resident License(s).
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
WI
WY
IA
KS
KY
LA
ME
MD
ND
OH
OK
OR
MA
MA
PA
MI
MN
MS
MO
MT
NE
NV
MI
MN
MS
MO
MT
NE
NV
RI
SC
SD
TN
TX
UT
VT
1
NH
NH
VA
NJ
NJ
NM
NY
NC
WA
WV
WI
WY
LTC690-MA/MANY/MAFL-Agency Profile 09/2011
AGENCY PROFILE (continued)
VII. Principal Signature and Corporate Code of Business Conduct Acknowledgement
I certify that all of the information provided above is true and accurate.
I acknowledge that I have received The Lifetime Companies (the “Corporation”) Code of Business Conduct. I have read the Code and
understand its purpose. I understand that the Code applies to me and all agents and employees of the Agency. I agree to abide by all of its
provisions. I understand that I have a duty to report any violations of the Code and that if I fail to report a violation of any provision of the Code
that I may face termination of my contract to represent the Corporation. Use of the words “me” or “my” or “you” or “your” shall mean not only
the individual signing, but also the corporation. The undersigned warrants and acknowledges that he/she has the necessary authority to
execute this Acknowledgement on behalf of the Agency.
Print Name of Principal of Agency Signing
Signature
Date
REMEMBER TO SUBMIT THE IRS FORM W-9 WITH THIS FORM TO VERIFY AGENCY TAX ID
ROUTING FORM (LTC685-RTE-9/2011) IS REQUIRED WITH THIS DOCUMENT
2
LTC690-MA/MANY/MAFL-Agency Profile 09/2011
Commission Producer Agreement
This Agreement is between MedAmerica Insurance Company, MedAmerica Insurance Company of New York, MedAmerica
Insurance Company of Florida; (hereinafter referred to as “Company”) and:
, the principal of
PRINT NAME OF PRINCIPAL (FIRST NAME, MIDDLE INITIAL, LAST NAME)
PRINT AGENCY NAME (if applicable)
(hereinafter referred to as “Producer”). All provisions of this Agreement shall be in effect when (a) signed by the Producer;
and (b) signed and accepted by the Company. This Agreement shall replace and supersede any prior Commission Producer
Agreement between Company and Producer and will remain in effect until terminated.
I)
RELATIONSHIPS & AUTHORITY:
A) RELATIONSHIP: The Producer is an independent contractor with respect to the Company. The relationship between the
Company and the Producer is not employer/employee, partners or joint ventures. The Company may from time to time
prescribe such rules and regulations with respect to the conduct of the business covered by this Agreement that do not
interfere with the Producer’s freedom of judgment and action hereunder. The Producer will observe such rules and
regulations and any manuals, published guidelines and/or specific instructions from the Company. The Producer will not
violate any laws, rules or regulations of any federal, state or local government, department or bureau having jurisdiction,
nor induce or try to induce any other Agent to violate such laws, rules or regulations. The Producer agrees to comply
with the Company’s requests for information on investigations for issuance of policies, resolutions of complaints and
adjudication of claims; this obligation shall survive the termination of this Agreement.
B) RECRUITMENT: The Producer will use their best efforts to recruit, train and supervise Producers and Agencies
(hereinafter referred to as “Downline”) to solicit applications for the Company’s Product(s) (hereinafter referred to as
“Products”), in those states where: (i) The Company has approved Products and; (ii) The Producer and Downline are in
compliance with any and all regulatory licensing and appointment requirements, if any.
C) SOLICITATION & APPOINTMENT: The Company authorizes the Producer to solicit the Company’s Products in those
states where: (i) The Company has approved Products; (ii) The Producer is in compliance with any and all regulatory
licensing requirements at the time of solicitation, if any, and; (iii) The Producer has been appointed by the Company, if
required, in accordance with all applicable laws. Applications submitted by a Producer to the Company that are dated
prior to the Producer’s appointment date will be returned.
D) HIERARCHY: The Producer acknowledges and accepts their place in the hierarchy of the Sponsoring General Agent
named in the Producer Profile and agrees to accept the guidance, supervision and management of said Sponsoring
General Agent. Producers requesting transfer from their current Sponsoring General Agent to another Sponsoring
General Agent may be transferred in accordance with the MedAmerica agent transfer policy and procedures in effect at
the time transfer is being requested. Transfers are allowable at the sole discretion of MedAmerica. MedAmerica will not
abide by nor enforce any third party transfer agreement between the producer and the Hierarchy
E) LIMITATIONS: The Producer shall not have the authority to: (i) Adjust, compromise, settle or pay any claim made on
Policies; (ii) Bind coverage under, or alter or discharge any policy; (iii) Make representations not strictly in accordance
with the provisions of the policies; (iv) Extend the time of payment of premium; (v) Waive or extend any policy obligation
or condition; (vi) Make any settlement or agreement regarding the settlement of any claim that may be made against the
Company; (vii) Receive any premium except the initial premium due on any policy issued under this Agreement; or
accept any initial premium other than by check or money order payable to the Company. The Producer shall hold all
initial premium payments and all other funds belonging to the Company in trust on behalf of the Company, and remit the
premium to the Company within twenty-one (21) calendar days after receipt thereof; (viii) Endorse checks payable to the
Company or incur any expense or obligation in the name of or on behalf of the Company; (ix) Solicit if the Producer’s
license(s) or appointment(s) expires or terminates for any reason; and (x) Directly or indirectly, induce or try to induce any
policyholder of the Company’s to discontinue the payment of any premium or lapse or surrender any policies of the
Company, except in cases of policy increases.
LTC682-Commissioned Producer-MA/MANY/MAFL-FINAL-09/11
X)
MISCELLANEOUS:
We reserve the right, with or without cause, to refuse to appoint or to terminate the appointment of the Producer or any
Downline producers. The Company is solely responsible for underwriting Applications, administering Product(s) and settling
policyholders’ claims. In the event that any provision of this Agreement should be held to be void, voidable, unlawful or, for
any reason unenforceable, the remaining portions hereto shall remain in full force and effect.
XI)
REPRESENTATION:
The signature below certifies and represents to the Company that the Producer: (i) Acknowledges that it has received or has
had the opportunity to receive independent legal advice from counsel of its choice with respect to this Agreement; (ii) Agrees
to the terms of this Agreement and the Commission Schedule(s) hereto; and (iii) Is properly licensed to solicit and/or collect
commission overrides on Company products. This Agreement may be executed via facsimile and such signatures shall be
considered originals for all purposes.
Agreed To By:
Producer
Producer’s Signature
Date
Producer’s Name (Please Print)
Agency Name (If Applicable)
MedAmerica Insurance Company
MedAmerica Insurance Company of New York
MedAmerica Insurance Company of Florida
William E. Jones, Jr., President and Chief Operating Officer
LTC682-Commissioned Producer-MA/MANY/MAFL-FINAL-09/11
Date
W-9
Form
(Rev. December 2000)
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.
Please print or type
Name (See Specific Instructions on page 2.)
Business name, if different from above. (See Specific Instructions on page 2.)
Check appropriate box:
Individual/Sole proprietor
Corporation
Partnership
Address (number, street, and apt. or suite no.)
Other
䊳
Requester’s name and address (optional)
City, state, and ZIP code
Part I
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. 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 2. 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 2.
Note: If the account is in more than one name, see
the chart on page 2 for guidelines on whose number
to enter.
Part III
List account number(s) here (optional)
Social security number
–
–
or
Part II
Employer identification number
–
For U.S. Payees Exempt From
Backup Withholding (See the
instructions on page 2.)
䊳
Certification
Under 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. person (including a U.S. resident alien).
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 2.)
Sign
Here
Signature of
U.S. person 䊳
Purpose of Form
A person who is required to file an information
return with the IRS must get 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 give your correct
TIN to the person requesting it (the requester)
and, when applicable, to:
1. Certify the TIN you are giving is correct (or
you are waiting for a number to be issued),
2. Certify you are not subject to backup
withholding, or
3. Claim exemption from backup withholding if
you are a U.S. exempt payee.
Date
What is backup withholding? Persons making
certain payments to you must withhold and pay
to the IRS 31% of such payments under certain
conditions. This is called “backup withholding.”
Payments that may be subject to backup
withholding include interest, dividends, broker
and barter exchange transactions, rents,
royalties, nonemployee pay, and certain
payments from fishing boat operators. Real
estate transactions are not subject to backup
withholding.
If you give the requester your correct TIN,
make the proper certifications, and report all
your taxable interest and dividends on your tax
return, payments you receive will not be subject
to backup withholding. Payments you receive
will be subject to backup withholding if:
1. You do not furnish your TIN to the
requester, or
2. You do not certify your TIN when required
(see the Part III instructions on page 2 for
details), or
If you are a foreign person, use the
appropriate Form W-8. See Pub. 515,
Withholding of Tax on Nonresident Aliens and
Foreign Corporations.
3. The IRS tells the requester that you
furnished an incorrect TIN, or
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.
4. The IRS tells you that you are subject to
backup withholding because you did not report
all your interest and dividends on your tax return
(for reportable interest and dividends only), or
Cat. No. 10231X
䊳
5. You do not certify to the requester that you
are not subject to backup withholding under 4
above (for reportable interest and dividend
accounts opened after 1983 only).
Certain payees and payments are exempt
from backup withholding. See the Part II
instructions and the separate Instructions for
the Requester of Form W-9.
Penalties
Failure to furnish TIN. If you fail to furnish your
correct TIN to a requester, you are subject to a
penalty of $50 for each such failure unless your
failure is due to reasonable cause and not to
willful neglect.
Civil penalty for false information with respect
to withholding. If you make a false statement
with no reasonable basis that results in no
backup withholding, you are subject to a $500
penalty.
Criminal penalty for falsifying information.
Willfully falsifying certifications or affirmations
may subject you to criminal penalties including
fines and/or imprisonment.
Misuse of TINs. If the requester discloses or
uses TINs in violation of Federal law, the
requester may be subject to civil and criminal
penalties.
Form
W-9
(Rev. 12-2000)
Automatic Deposit
of
Commission Payments
Use this form for MedAmerica Insurance Company(116) and Principal Financial Group(119)
Account Holder Name:
(Please Print)
Contact Name (If Company Name and not Individual):
(Please Print)
Address:
(Please Print)
Phone Number: (
Street
City
State
Zipcode
)
Bank Name:
Bank Account #:
ABA Number (always 9 digits):
Account Type
Checking (Attach a Voided Check)
Savings
Credit Union
Note: With Savings accounts and Credit Unions be sure you have checked with your financial institution and recorded the
correct ABA number and Account Number.
I authorize MedAmerica Insurance Company to automatically deposit commission payments due
to the Account Holder named into the bank account specified above. This authorization shall
remain in force until I give notification of termination to MedAmerica Insurance Company or my finanical
institution in writing.
X
X
Signature of Account Holder
Count on us for the long term.
Date
Signature of Joint Account Holder
Date
AutomaticDepsit_MEDAM_2004
Credit Card Authorization Form
Please complete and fax to 866-436-1640
Name on Card: _______________________________________
Card Type: ______Visa
______Mastercard
______Discover
______Amex
Card#: ______________________________________________
Expiration Month: __________ Expiration Year: __________
3-Digit Security Code: __________
(Amex has 4 digits!)
Purpose(s) for charge(s): _______________________________
____________________________________________________
____________________________________________________
_______Check here if you would like your card kept on file for future charges and uses.
I authorize Premier Companies to charge my credit card listed above
________________________________________
______________
Signature
Date
Revised 6-2013
DISTRIBUTOR BRIEF
National Account Manager:
Territory:
Phone number:
Fax number:
All confidential and proprietary information will be kept in the strictest of confidence and will be shared only with
those that are involved in the approval process.
Part I.
Background Information
(If handwritten, please write neatly for clarification)
Date:
Principal Name:
Agency Name:
Principal Title:
Address1:
LTC Marketing Specialist:
Address2:
Administrative Contact:
City, State:
Administrative Phone #:
Zip code:
How long in LTCI Business?
Phone #:
What percent of business is LTCI?
Fax #:
Percent of other product lines sold:
Email Address:
Distribution by State: ___________________________________________________________________________
Is your agency best classified as:
Brokerage
Personal Producing
Employee Benefits Consultants
Career
Executive Compensation
Commercial Group Insurance
TPA
List Distribution Sources by percentage:
General Agents _____% Career Agents ______% Individual Brokers ______% Enrollment Specialists ______%
What are your primary target markets?
Individual Policy Sales
Individual Policy Sales on a Group Basis
True Employer Group Products with Certificates*
_________ %
_________ %
_________ %
*Client Demographics for True Group Employees:
5-99
_________ %
100-499
_________ %
500-2,499
_________ %
2500+
_________ %
Industry Segments
Professional
Non-Profit
Manufacturing
Rev1.23.08
Banking
Municipalities
School Districts
Other (describe): ___________________________
DISTRIBUTOR BRIEF
Part II.
General Information /Agent Contracting Information
1. How did you hear about MedAmerica?
Magazine Ad.
Web Site
LTC Agents/GAs
LTC Seminar
Other _______________________
2. How many agents do you anticipate contracting with MedAmerica in the first 3 months of
partnership?________________________________________________________________________________
3. A) Who will be responsible for commission payment to your agents?
MedAmerica
Your Agency
B) Who should we mail policies, correspondence, premium notices, etc. to?
Your agency
Directly to writing agent
Other _________________________
4. Number of commission level contracts needed?
5. How will you recruit agents/brokers for MedAmerica appointments?
6. What types of incentives do you offer agents?
7. Do you offer to provide sales leads?
8. What is your method for training agents?
9. Why are you interested in selling LTCI for MedAmerica? Are there specific niches that are beneficial to you?
10. What other LTCI companies are you contracted with?
11. Where will MedAmerica fit in your current LTCi carrier portfolio? (i.e. #1, #2, #3) _______________
12. What has been your annualized placed LTCI production for the following time periods:
Last 6 Months
$
12 Months
$
24 Months
$
Rev1.23.08
Part II. Con’t.
General Information /Agent Contracting Information
13. Please include supporting documentation of past production.
(i.e., Annual production reports, Commission statements, Sales leader publication)
14. Are you agreeable to host an orientation meeting with your staff and MedAmerica to better acclimate you to
Yes
No
our products and procedures?
15. Are you agreeable to participate and have your agents participate in Web cast seminars to familiarize them with
Yes
No
MedAmerica products?
Importance Scale (1-8)
Rank the following list in order of importance 1-8, 1 being the most important.
Price
_____
Sales/ Enrollment Support
_____
Product
_____
Underwriting
_____
Name Recognition
_____
Customer Service
_____
Commissions
_____
Time Service
_____
Please provide a brief description of your marketing strategy:
Thank you for providing this information and for your interest in partnering with MedAmerica Insurance Company.
We look forward to working with you and [ABC Agency].
Agent Contracting Receipt Date:
MedAmerica Staff Comment Section:
Name:
Date:
FOR OFFICE USE ONLY
Customer Service Representative: ________________________________________________
Sales Support Representative: ___________________________________________________
Rev1.23.08
Commission Schedule
SIMPLIFIED-ALL PROGRAMS
Available in All Approved States 1 Excluding California, Delaware, Indiana, Michigan, Pennsylvania & Wisconsin
DC Trust – Available in New Jersey
You shall receive the indicated percentage of the premium collected less premium refunded for each corresponding state
approved long-term care insurance policy which You solicited and placed with MedAmerica Insurance Company,
MedAmerica Insurance Company of Florida, or MedAmerica Insurance Company of New York.
Individual/Association/Employer Sponsor Sales
Policy
Applicant
Pay Term
Year
Age
Commission
Lifetime
1 18-64
55%
Lifetime
1 65-85
45%
Lifetime
2-10 18-85
5%
Lifetime
11+ 18-85
2%
10 Year
1 18-85
35%
10 Year
2-10 18-85
2%
10 Year
11+ 18-85
0%
Paid @ 65
1 18-55
35%
Paid @ 65
2-10 18-55
2%
Paid @ 65
11+ 18-55
2%
Replacement Policies:

Commission for the sale of long-term care policies which replace an existing long-term care policy in the states of Alabama,
California, Kentucky, New York, North Carolina and South Dakota shall not be greater than the percentage payable for renewal
commissions.

Replacement of policies which were written or reinsured by MedAmerica Insurance Company, MedAmerica Insurance Company of
Florida or MedAmerica Insurance Company of New York will be paid renewal commission.

Year 1 commissions, where not prohibited by law, or the policy replaces a policy previously written or reinsured by MedAmerica
Insurance Company, MedAmerica Insurance Company of Florida or MedAmerica Insurance Company of New York.
Agreed To By:
Signature of Agency Principal
Title
(owner/president\person with authority to sign)
For MedAmerica Use Only
State(s)
Effective Date
Writing Number
Date
Print Name and Title (Required):
Print Agency Name:
Effective for applications solicited and signed 1/1/2013 and after.
1
Nonresident Agencies in AL/GA/MA/MT/NM/PA/SC/VA/WV must be licensed to receive overrides-Please include a copy of your
license(s). In AL/MA/VA appointment is required to receive overrides- Also include a check made payable to “MedAmerica
Insurance Company” for applicable fees.
Nonresident Agents in AL/FL/GA/MA/MT/NM/PA/SC/VA/WI/WV must be licensed to receive overrides-Please include a copy of
your license(s). In AL/FL/GA/MA/VA appointment is required to receive overrides- Also include a check made payable to
“MedAmerica Insurance Company” for applicable fees.
S2 Earned 2013 DL4_55.5.2
Annualized Commission Schedule
Available in All Approved States, Except Where State Regulations require variation
Year 1 (Annualized): In keeping with the terms and conditions of Your Annualized Commission Advance
Program Addendum You shall receive an amount equal to seventy five percent (75%) (“Advance
Percentage”) of the anticipated Year One Commission identified below for each corresponding state
approved policy which You solicited and delivered with MedAmerica Insurance Company, MedAmerica
Insurance Company of Florida, or MedAmerica Insurance Company of New York (collectively,
“MedAmerica”). The anticipated Year One Commission is based upon the projected annual premium
MedAmerica expects to collect, less any premium refunded, during Year One for an applicable policy. The
remaining percent of the Advance Commissions will be applied to Your Escrow, as defined by Your
Annualized Commission Advance Program Addendum. Participation in this program, as well as the
Advance Percentage, is at the sole discretion of MedAmerica and may be adjusted prospectively from time
to time.
Years 2+ (Earned): You shall receive the indicated percentage of the premium collected less premium
refunded for each corresponding state approved policy which You solicited and placed with MedAmerica.
Pay Term
Lifetime
Lifetime
Policy Year
Lifetime
1
2-10
Applicant Age
18 - 85
18 - 85
11+
18 - 85
Commission
50
9
0
Replacement Policies:
Replacement of policies which were written or reinsured by MedAmerica Insurance Company, MedAmerica
Insurance Company of Florida or MedAmerica Insurance Company of New York will be paid renewal
commission. Renewal commissions will also be paid where required by state law.
Agreed To By:
For MedAmerica Use Only
State(s)
Annualization
Effective Date
Writing Number
Signature
Date
Commissioned Producer (If Agency then Owner\president\person with authority to sign)
Print Name and Title (Required):
Print Agency Name:
Effective for applications solicited and signed 1/1/2013 and after.
1
Nonresident Agencies in AL/GA/MA/MT/NM/PA/SC/VA/WV must be licensed to receive overrides-Please include a copy of your license(s). In AL/MA/VA
appointment is required to receive overrides- Also include a check made payable to “MedAmerica Insurance Company” for applicable fees.
Nonresident Agents in AL/FL/GA/MA/MT/NM/PA/SC/VA/WI/WV must be licensed to receive overrides-Please include a copy of your license(s). In
AL/FL/GA/MA/VA appointment is required to receive overrides- Also include a check made payable to “MedAmerica Insurance Company” for applicable fees.
Transitions 2013 Annualized Schedule DL4-5_50.9.0
Earned Commission Schedule
1
Available in All Approved States Excluding Delaware, Indiana, Michigan, New York, Pennsylvania & Wisconsin
You shall receive the indicated percentage of the premium collected less premium refunded for each corresponding state
approved long-term care insurance policy which You solicited and placed with MedAmerica Insurance Company,
MedAmerica Insurance Company of Florida, or MedAmerica Insurance Company of New York.
Individual/Association/Employer Sponsor Sales
Pay Term
Policy Year
Lifetime
Lifetime
Lifetime
Lifetime
10 Year
10 Year
10 Year
20 Year
20 Year
20 Year
20 Year
20 Year
1
1
2-10
11+
1
2-10
11+
1
1
2-10
11-20
21+
Applicant Age
18-64
65-85
18-85
18-85
18-85
18-85
18-85
18-64
65-85
18-85
18-85
18-85
Commission
55%
45%
5%
2%
35%
2%
0%
55%
45%
5%
2%
0%
Replacement Policies:

Commission for the sale of long-term care policies which replace an existing long-term care policy in the states of Alabama,
California, Kentucky, New York, North Carolina and South Dakota shall not be greater than the percentage payable for renewal
commissions.

Replacement of policies which were written or reinsured by MedAmerica Insurance Company, MedAmerica Insurance Company of
Florida or MedAmerica Insurance Company of New York will be paid renewal commission.

Year 1 commissions, where not prohibited by law, or the policy replaces a policy previously written or reinsured by MedAmerica
Insurance Company, MedAmerica Insurance Company of Florida or MedAmerica Insurance Company of New York.
Agreed To By:
Signature of Agency Principal
Title
(owner/president\person with authority to sign)
For MedAmerica Use Only
State(s)
Effective Date
Writing Number
Date
Print Name and Title (Required):
Print Agency Name:
Effective for applications solicited and signed 1/1/2013 and after.
1
Nonresident Agencies in AL/GA/MA/MT/NM/PA/SC/VA/WV must be licensed to receive overrides-Please include a copy of your
license(s). In AL/MA/VA appointment is required to receive overrides- Also include a check made payable to “MedAmerica
Insurance Company” for applicable fees.
Nonresident Agents in AL/FL/GA/MA/MT/NM/PA/SC/VA/WI/WV must be licensed to receive overrides-Please include a copy of
your license(s). In AL/FL/GA/MA/VA appointment is required to receive overrides- Also include a check made payable to
“MedAmerica Insurance Company” for applicable fees.
FLEXCARE- 2013 Earned DL4_55.5.2