NATIONAL HEALTH INSURANCE COMPANY
SUB-AGENT’S APPOINTMENT .........
National Health Insurance Company Date
Attn: Agency Operations Department
P.O. Box 619999
Dallas. TX 75261
Agency Operations’ Number: 1-800-237-1930
Note: Checklist must be completed in full. Incomplete packets will be returned. Call your licensing
representative with any questions. Please return the completed packet and appropriate fees to above
WILLIAM E SMALLWOOD II 602093
Agency Name: License Number:
SUB-AGENT APPOINTMENT APPLICATION Completed in full, signed and dated.
NOTIFICATION OF BACKGROUND INVESTIGATION signed and dated.
BUSINESS ASSOCIATE AGREEMENT signed and dated.
ADVERTISING RULES AND PROCEDURES signed and dated.
LICENSE/APPOINTMENT FEES $__________ attached. (Money Order, check made payable to NHIC or
Credit card payment form.) All license/appointment fees must be included with contracting packet. Check
with applicable state for amount to submit.
Authorized Agency Signature Date
Sub Agent Information Packet 05/09
National Health Insurance Company
SUB-AGENT APPOINTMENT APPLICATION
PART 1 — AGENCY INFORMATION
PART 2 — AGENT INFORMATION
PLEASE TYPE OR PRINT
(FIRST) (MI) (LAST)
DOB (MM-DD-YYYY) ADDRESS
E-MAIL ADDRESS CITY
WEB SITE ADDRESS STATE ZIP
STATES TO APPOINT PHONE
PART 3 — QUESTIONS
1 Do you have any indebtedness with an agency or company?
If Yes, give name:
2 Have you been convicted of a felony in the last 10 years, or misdemeanor, other than a non-DUI traffic offense, in the last 5 years?
If Yes, please give brief details in the notes section. O O
3 Have you ever had your insurance agent’s license or other professional licenses suspended or revoked, or are you now, or have
you ever been the subject of a professional license or market conduct investigation or proceeding? O O
If Yes, please give brief details in the notes section.
4 Are you now or have you ever been the subject of any lawsuit or investigation alleging the breach of trust or fiduciary duty, forgery,
fraud or any other act of dishonesty? O O
If Yes, please give brief details in the notes section.
5 Have you been previously appointed with National Health Insurance Company? O O
If Yes, when?
PART IV — SIGNATURES
I understand that no contract other than an appointment exists or shall exist between myself and National Health Insurance Company (NHIC) and that all
commissions are payable by NHIC to the agency listed in Part 1 above. All compensation and/or reimbursement for expenses due me, if any, for producing
insurance business through my appointment with NHIC is strictly and solely a contractual matter between the agency listed in Part 1 above any myself; and
under no circumstances whatsoever shall I have any legal claim against NHIC for compensation, commissions, expenses, or any other payment. I also under-
stand that NHIC reserves the right to terminate my appointment. By signing below I also acknowledge Public Law 91-508 requirements that a routine inquiry
may be made during initial or subsequent processing which will provide additional financial and personal background information, any criminal history
recorded information pertaining to me which may be in the files of any state or local criminal justice agency, or any law enforcement agency. By signing this
application, I hereby consent to the Company obtaining such information from time to time as it deems necessary through independent investigation and/or
through a consumer report obtained from a consumer reporting agency. I hereby certify that the information provided herein is accurate and complete.
Agent Signature Date
I understand that I am solely responsible for the sub-agent. I will be respon-
sible for training, providing supplies, and any correspondence from NHIC. Signature Authorized Officer—NHIC Date
I understand that NHIC reserves the right to terminate this sub-agent
NMO/IMO/MGA Signature Date
National Health Insurance Company
Notification of Background Investigation
As a condition of your appointment with National Health Insurance Company located at 1901 N State
Hwy 360, Grand Prairie, TX 75050, an investigative consumer report may be obtained from a Consumer
Reporting Agency (General Information Services or other service provider). The investigative consumer
report is being obtained for the purpose of evaluating you in accordance with The Fair Credit Reporting
Act 15 U.S.C. §1681b §604 (a) (3). This report may contain information bearing on your credit
worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or
mode of living from public record sources or through personal interviews with your neighbors, friends or
associates. You may have a right to request additional disclosures regarding the nature and scope of the
Authorization to Conduct Background Investigation
I hereby authorize and request any present or former employer, school, police department, financial
institution or other persons having personal knowledge about me, to furnish National Health Insurance
Company with any and all information in their possession regarding me in connection with my
submission of the General Agent’s Application. I am willing that a photocopy of this authorization be
accepted with the same authority as the original and I specifically waive any written authorized request. I
understand this authorization is to be part of the written General Agent’s Application that I signed.
I have been given consumer notification that a report may be requested.
Print Name: __________________________________________________________________________
Date of Birth (for identification purposes only): ______________________________________________
Social Security Number (for identification purposes only): _____________________________________
If name changed (through marriage or otherwise) print former name(s): ___________________________
Signature: __________________________________ Date: ___________________________
BUSINESS ASSOCIATE AGREEMENT
FOR USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
WHEREAS, this Exhibit A shall be applicable to Protected Health Information (i) received by Agent from
Company or (ii) created or received by Agent on behalf of Company. Such Protected Health Information may be used
or disclosed only in accordance with this Agreement and the Health Insurance Portability and Accountability Act of
1996 (“HIPAA”) and regulations promulgated by the U.S. Department of Health and Human Resources (“HIPAA”
Regulations”) and other applicable laws; and
WHEREAS, THE COMPANY may make available and/or transfer to AGENT certain information, in conjunction
with goods or services that are being provided by AGENT to THE COMPANY, that is confidential and must be afforded
special treatment and protection, and
WHEREAS, it is specifically understood by the parties hereto that the provisions of this Exhibit A may be modified
prospectively from time to time.
NOW THEREFORE, in consideration of the mutual covenants herein contained and for other good and valuable
consideration, it is agreed as follows:
1. DEFINITIONS: Except as otherwise defined herein, any and all capitalized terms in this Section shall have the
definitions set forth in the HIPPA Regulations, defined below. In the event of an inconsistency between the provisions
of this Agreement and mandatory provisions of the HIPPA Regulations, as amended, the HIPPA Regulations shall
control. Where provisions of this Agreement are different than those mandated in the HIPPA Regulations, but are
nonetheless permitted by the HIPPA Regulations, the provisions of the Agreement shall control.
a. PROTECTED HEALTH INFORMATION (“PHI”) shall mean individually identifiable health information including,
….without limitation, all information, data, documentation, and materials, including without limitation, demographic,
….medical and financial information, that relates to the past, present, or future physical or mental health or
….condition of an individual; the provision of health care to an individual; or the past, present, or future payment for
….the provision of health care to an individual; and that identifies the individual or with respect to which there is a
….reasonable basis to believe the information can be used to identify the individual.
b. HIPAA Regulations shall mean the Standards for Privacy of Individually Identifiable Health Information at 45
....CFR part 160 and part 164, subparts A and E and the Security Standards at 45 CFR parts 160 and 162 and part
....164 Subpart C.
c. SECRETARY shall mean the Secretary of the Department of Health and Human Services (“HHS”) and any other
….officer or employee of HHS to whom the authority involved has been delegated.
d. USE shall mean, with respect to PHI, the sharing, employment, application, utilization, examination, or analysis
….of such information within an entity that maintains such information.
e. DISCLOSE (or DISCLOSURE) shall mean the release, transfer, provision of access to, or divulging in any other
....manner of information outside the entity holding the information.
2. LIMITS ON USE AND DISCLOSURE: AGENT agrees that all PHI in any form, including paper record, oral
communication, audio recording, and electronic display DISCLOSED to AGENT, or created or received by AGENT on
THE COMPANY’s behalf shall be subject to this Agreement. AGENT agrees that it shall be prohibited from USING or
DISCLOSING PHI provided or made available by THE COMPANY for any purpose other than as expressly permitted
or required by this Agreement.
3. PERMITTED USE AND DISCLOSURE: AGENT agrees to USE or DISCLOSE any PHI solely for the purpose of:
a. For meeting obligations as set forth in any agreements between THE COMPANY and AGENT;
b. For the proper management and administration of the AGENT;
c. As required by applicable law, rule or regulation, or by accrediting or credentialing organization to whom THE
…COMPANY is required to DISCLOSE such information or as otherwise permitted under this Agreement, the
…existing Administrative Agreement (if consistent with this Agreement) and the HIPPA Regulations
d. As would be permitted by the HIPPA Regulations if such USE or DISCLOSURE were made by THE COMPANY.
4. AVAILABILITY OF INFORMATION: AGENT agrees to make information available to The Company for their
obligations to provide access to, provide a copy of and account for disclosures with respect to PHI pursuant, but not
limited to, Sections 164.524, 164.526 and 164.528 of the HIPAA Regulations.
a. The AGENT agrees to make information available to the Secretary for the purpose of auditing AGENT’s records,
books and practices related to USE and DISCLOSURE of PHI received from, or created or received by AGENT on
behalf of, THE COMPANY to ensure THE Company’s compliance with the HIPAA Regulation. AGENT will notify
THE COMPANY immediately upon receipt of a request from the Secretary.
5. ACCESS TO BOOKS AND RECORDS: AGENT agrees to makes its internal practices, books and records relating
to the USE and DISCLOSURE of PHI received from, or created or received by AGENT on behalf of, THE COMPANY
available to the Secretary for purposes of determining THE Company’s compliance with the HIPAA Regulation.
6. SAFEGUARDS AND REPORTING: AGENT agrees to implement appropriate safeguards to prevent USE or
DISCLOSURE of PHI other than as provided for by this Agreement, and to implement procedures for mitigating, to the
maximum extent practicable, any deleterious effect from such USE or DISCLOSURE of PHI. Within 2 (two) working
days from the date AGENT becomes aware of a use or disclosure Agent agrees to report to THE COMPANY any USE
or DISCLOSURE of PHI not provided for by this Exhibit A.
7. DURATION OF AGREEMENT: This Exhibit A shall be effective as of the effective date of the Agent Commission
Agreement to which this Exhibit A is attached. Termination of this Exhibit A will commence upon the earlier of the
a. On the date of termination of the existing Agent Commission Agreement between THE COMPANY and AGENT
b. On the date of termination of the AGENT’s appointment with THE COMPANY; or
c. If THE COMPANY determines AGENT has violated a material term of this Exhibit A.
8. UPON TERMINATION: Upon termination of this Exhibit A, AGENT agrees to return or destroy all PHI received
from, or created or received by the AGENT on behalf of, THE COMPANY that the AGENT still maintains in any form
and retain no copies of such information. If return or destruction of any portion of PHI is not feasible, AGENT agrees to
extend the protections of the contract to the information and limit further USE and DISCLOSURE to those purposes
that make the return or destruction of the information infeasible. If AGENT elects to destroy the PHI, it will present THE
COMPANY with certification of the destruction.
AGENT agrees that its duty to return or destroy PHI, as well as its duty to protect the privacy of PHI it created for or
received from, or on behalf of, THE COMPANY during the term of this Exhibit A and the accompanying Agent
Commission Agreement, survives termination of this Exhibit A and the accompanying Agent Commission Agreement.
9. SUBCONTRACTORS AND AGENTS: AGENT agrees to ensure that any agent or subcontractor to whom it
provides PHI received from THE COMPANY, or created or received by the AGENT on behalf of THE COMPANY,
agrees to the same restrictions and conditions that apply to the AGENT with respect to such information.
10. ASSIGNABILITY OF AGREEMENT: AGENT shall not assign or transfer its rights or obligations under this Exhibit
A without prior written consent of THE COMPANY.
11. AMENDMENT OF AGREEMENT: No changes in or additions to this Exhibit A shall be recognized unless and until
made in writing and signed by an authorized officer or agent of THE COMPANY and AGENT; provided however, that
this Exhibit A shall be deemed amended or modified, as necessary, to comply with the requirements imposed by state
or federal law governing the privacy of Protected Health Information.
12. INDEMNIFICATION: AGENT agrees to indemnify, defend and hold harmless THE COMPANY, its parent
companies, subsidiaries, affiliates, agents, officers, directors and employees from and against any and all liability or
expense, including defense costs and legal fees, incurred in connection with claims for damages of any nature,
including but not limited to bodily injury, death, personal injury, property damage or other damages arising from the
negligent or willful performance or failure to perform its obligations under this Exhibit A.
Agent National Health Insurance Company
Name of Agent (please print) Authorized officer of National Health Insurance Company
Date Accepted Date Accepted
Advertising Rules and Procedures
State laws specify that National Health Insurance Company (NHIC) is required to maintain an
advertising file which must contain a record of all advertising both by the company itself and also
by its sales representatives. This file is subject to examination by any of the state Insurance
Departments at any time and is a normal part of the periodic financial and market conduct
examination of each insurer by its’ home state Insurance Department.
Your General Agent’s Contract with the Company requires that all advertising material must be
approved in writing by the Home Office prior to use. The term "Advertisement" is very broad and
includes but is not limited to:
(a) Printed and published material, audio visual material, and descriptive literature used in direct
mail, newspapers, magazines, radio scripts, TV scripts, web sites and other Internet displays or
communications, other forms of electronic communications, billboards and similar displays;
(b) Descriptive literature and sales aids of all kinds for presentation to members of the insurance-
buying public, such as circulars, leaflets, booklets, depictions, illustrations, form letters and lead-
generating devices of all kinds; and
(c) Prepared sales talks, presentations and materials for use by agents.
The established procedure for Home Office advertising approval and use includes five steps:
1. Work with your Managing General Agent to prepare your own advertising material or to
obtain material previously approved for another agent that you would like approved for
2. Submit your proposal to the Home Office with the Request For Ad Approval form
(signed by your Managing General Agent) indicating how, when and where the proposed
material will be used.
3. If needed, make any required corrections requested by Submission and Compliance and
then resubmit the advertising material.
4. After final approval is received, use advertising only in the way described on your original
request. Each approval is only for the person(s) listed in the request. If you change the
approved material or its usage, then you must submit another Request for Ad Approval.
5. Maintain your own personal advertising file, keeping drafts and final approval forms
together. You should maintain your file for a minimum of five years.
“I understand these requirements and agree to comply and ensure local compliance
within the scope of my marketing area.”
General Agent’s Signature Date
Printed General Agent’s Name Agent’s Number
Please sign and return with Agent Information Pack
National Health Insurance Company
1901 North State Highway 360 ● Grand Prairie ● Texas ● 75050
Producer Appointment Credit Card Payment Form
PLEASE USE A SEPARATE FORM FOR EACH AGENT OR AGENCY BEING APPOINTED
1. Circle the states to indicate in which you wish to be appointed. (resident or non-resident)*
*Note that some states charge different fees for agent or agency.
2. Complete and sign the form below to pay appointment fees by credit card.
Agency Name (if an agency is being appointed) Agency Resident State
Producer’s Last Name (If producer is being appointed) Producer’s First Name Producer’s Resident State
CARDHOLDERS INFORMATION (Please Print)
Last Name First Name
Street Address State Postal Code
Email Address Telephone Number Fax Number
AUTHORIZATION AGREEMENT: (When paying Credit Card please complete the section below)
As a convenience to me, I authorize National Health Insurance Company to initiate entries to my bank credit card account
for my state appointment fee(s). I understand this will occur as soon as my appointment is approved and that such record
will appear on my monthly statement. I agree that if any such charge be dishonored, whether with or without cause and
whether intentionally or inadvertently, the bank or credit card company shall be under no liability whatsoever.
Master Card Visa
____________________________________________________, _______________, ____________________________________________________
Credit Card Holder’s Name Date Credit Card Holder’s Signature
Credit Card # _____________________________________________________ Expiration Date _______/____/______
Credit Card payment will be processed after the appointment(s) are approved by the state(s)
STATE RESIDENT NON- STATE RESIDENT NON- STATE RESIDENT NON-
RESIDENT RESIDENT RESIDENT
AL $30.00 $30.00 KS $5.00 $5.00 NM $23.00 $23.00
AK No fee No fee KY $100-AGCY $120-AGCY OH $20.00 $20.00
AZ No fee No fee LA $20.00 $20.00 OK $40.00 $40.00
AR No fee No fee ME $70.00 $70.00 OR No fee No fee
CA $24.00 $24.00 MD No fee No fee PA $15.00 $15.00
CO No fee No fee MA $75.00 $75.00 RI No fee No fee
CT $20.00 $20.00 MI $5.00 $5.00 SC No fee No fee
D.C. $25.00 $25.00 MN $10.00 $10.00 SD $10.00 $20.00
DE $25.00 $25.00 MS $10.00 $10.00 TN $15.00 $15.00
FL $60.00 $60.00 MO No fee No fee TX $10.00 $10.00
GA $20.00 $20.00 MT No fee No fee UT No fee No fee
HI No fee No fee NC $20.00 $20.00 VT $60.00 $60.00
ID No fee No fee ND $10.00 $10.00 VA $12.00 $12.00
IL No fee No fee NE $8.00 $8.00 WA $20.00 $20.00
IN No fee No fee NV $15.00 $15.00 WV $25.00 $25.00
IA $10.00 $10.00 NH $25.00 $25.00 WI $7.00 $24.00
NJ $25.00 $25.00 WY $15.00 $15.00