This agreement is made between a company and an agent whereby the company
grants to the agent the power and authority to receive and accept any and all proposals
for insurance covering the risks which the company may take from time to time. The
agreement sets forth the terms and conditions of the agent's duties, including that the
agent will hold in trust any insurance premiums collected by the agent, the agent shall
refund the company any sums that may be due and owing in respect to cancelled
policies, and the agent will report as directed to the company and maintain a complete
record of transactions. This document is useful to companies that engage an agent to
handle insurance matters.
AGENT TO ACCEPT FUNDS AS FIDUCIARY
THIS AGREEMENT (the “Agreement”) is made the ____ day of __________, 2_____,
[Instruction: Insert date.] by and between ______________________ [Instruction: Insert
Company name.] (the “Company”) and _________________ [Instruction: Insert Agent
name.] (the “Agent”).
THE COMPANY AND THE AGENT HEREBY ACKNOWLEDGE AND AGREE AS
1. The Company hereby grants to the Agent (provided the Agent is properly licensed) the
power and authority to solicit, receive and accept in the State of _____ [Instruction:
Insert state.], any and all proposals for insurance covering any and all of the risks which
the Company may cover from time to time, to be administered by the Company, and to
perform such other acts as are incidental to such proposals. The Agent shall have the
power and authority to receive any and all insurance premiums which are tendered to the
Agent, provided that the Company has accepted same. The Agent shall keep, as full and
final payment, any such sums from the insurance premiums received, in respect with
business placed with the Company or any other such sums as the Agent and the Company
may in writing agree.
2. The Agent acknowledges and agrees that he or she shall refund to the Company, any and
all sums which may be due and owing in respect to any business of the Company in
respect to cancelled policies and on reductions in respect to insurance premiums.
3. Any and all insurance premiums which are collected and retained by the Agent shall be
held in trust by the Agent until such time payment has been made to the Company. Any
and all accounts of money which may be due and payable or become due and payable to
the Company on the business placed by the Agent with the Company shall be rendered to
the Company on a _____________ (weekly/monthly) [Instruction: Insert applicable
information and choose weekly or monthly. Delete inapplicable.] basis and shall be
rendered to the Company by no later than the _____ [Instruction: Insert date.] day of
each and every month.
4. Agent will report promptly as directed by the Company on all transactions of insurance by
Agent or modifications thereof, and is to maintain a complete record of transactions with
the Company's inspection at all times.
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5. [Optional language-if inapplicable delete.] Agent agrees that the Company shall not be
responsible for any of Agent's expenses whatsoever, including but not limited to rentals,
transportation, facilities, computer terminals and modems at agent's site and at Company
site, phone lines, clerical hires, solicitors fees, postage, advertising, personal license fees
and taxes. Supplies furnished the Agent shall remain the property of the Company and all
property of the Company shall be returned promptly on demand.
6. [Optional language-if inapplicable delete.] Agent agrees that nothing contained herein
shall be construed to create the relationship of employer and employee between Company
and Agent, or any sub-agent of Agent.
7. Failure of Company to promptly declare a default for breach of any of the terms and
conditions, hereof, shall not be construed as a waiver of any said terms and conditions, nor
estop Company from, thereafter, demanding a full and complete compliance therewith.
8. All accounting records of the Company pertaining to the business of the Agent shall be
subject to inspection at any reasonable time, during regular office hours, by the Agent or
authorized representative of said Agent.
9. Agent agrees to provide all necessary data (forms, computer tapes, etc.) to Company for
initiation of new accounts.
10. It is agreed that the responsibility of selling and servicing accounts rests with the Agent.
11. It is agreed that the final determination on the termination of a specific account due to
adverse loss ratio or lack of production rests with the Company.
12. Company and Agent agree that this agreement may be terminated by either party giving
the other party ten (10) days’ notice in writing of such intention or if one or more of the
following exist: (i) death or dissolution of the agent or agency; or (ii) loss of license by the
agent or agency.
13. It is agreed that cancellation of this Agreement does not cancel Agent’s responsibility to
refund, to the Company, any commission due the Company on return premiums at the
same rate as the applicable commission originally paid on such business.
14. It is further agreed by Company and Agent that should a dispute arise out this Agreement
that it be settled in ___________________ [Instruction: Insert jurisdiction for
15. This Agreement supersedes all previous agreements, whether oral or written, between the
Agent and Company, and may be terminated by either party in accordance with terms
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IN WITNESS WHEREOF the parties hereto have duly executed this Agreement
as of the day and year first written above.
I have authority to bind the Company.
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