allianz by zhangyun

VIEWS: 13 PAGES: 12

									      THANK YOU FOR CONTRACTING WITH ONE OF OUR CARRIERS!
 PLEASE COMPLETE THE ATTACHED APPOINTMENT PACKET & THIS SHEET.
    THEN, MAIL, FAX OR E-MAIL TO YOUR ASSIGNED REPRESENTATIVE:

                                            Brokers Alliance, Inc.
                                            P.O. Box 17634
                                            Fountain Hills, AZ 85269

                                ** FAX TOLL-FREE TO: (866) 302-0734 **

Anti-Money Laundering Training Requirement*
        □ AML training was completed via LIMRA on ___/___/___; or,
        □ AML training was completed via an independent program (completion certificate attached).
*If you have not met your AML training requirement, please visit our website for the LIMRA training link.


                                Please indicate your Representative below.
                      If you have any questions, CALL TOLL-FREE: (800) 290-7226.

        □ GARY BAKER x121                                                      □ CAYSE MERSCH x108
        □ ANNA BANKS x112                                                      □ DAVID NICKSIC x139
        □ JOE CECERE x131                                                      □ ERIC PALMER x103
        □ HOLLY CHIN x123                                                      □ MATT PROVOST x115
        □ JARED DEARDEN x138                                                   □ DAVID RACICH x111
        □ MICHAEL DECKER x132                                                  □ JOSEPH RACICH x102
        □ MARK GRAHAM x120                                                     □ RANDY ROBERTS x107
        □ AARON GRAVEL x141                                                    □ MIKE STRICKER x109
        □ DAVE LaBOUNTY x128                                                   □ JOHN WALLACE x130
        □ JESSICA LOPEZ x106                                                   □ LISA WINK x117

                                      Brokers Alliance Communication
Brokers Alliance distributes carrier product updates, licensing notices and case status memos via email
notification. Please provide us with a valid email address below permitting us to send such updates and notices.

  Please check this box permitting Brokers Alliance to send email communication to the below email address:
                      __________________________________________E-mail Address**
** By not providing us with your email address, there is no way for Brokers Alliance to communicate carrier product updates, case
management status, Brokers Alliance commission/bonus changes and much more.
                           Selling Agreement for



Required Paperwork:
 1.   Complete the following ( 8 ) pages
 2.   Copy of Insurance License
 3.   Copy of LTC Certification (if applicable)
 4.   Commission Advancement Application (available upon request)
 5.   Anti-Money Laundering Training Requirements*
       AML training was completed via LIMRA on ___/___/___ : or,
        AML training was completed via an independent program (completion certificate attached).
        I understand that once my contract has been processed by the home office I will also be
          required to complete the carrier specific training on the LIMRA website.

      *If you have not met your AML training requirement or need to complete the carrier specific
       training, please visit sunderlandgroup.com for the LIMRA training link.




Remit Paperwork to:




                          Fax: 800.293.9897
                        E-mail: licensing@sunderlandgroup.com
                          Mail: 2102 Great Northern Drive
                                Fargo, ND 58102

                                       Questions Call
                                        800.373.9807
%
  
 

 #
  
  %

 $ +'0*0                     




 4  ++,+'300*0     +)0/ 
  "
 
(001'+03/'*.                   

 4  ++,/*3/.')

                                                       /
 /

                                              # 
  + '
 % 


, 
 6 
5
,! M!  !!  
  ! L<                          /
  0 6+'% /5


) ! MJ  J !J L<                                  8
 !



6!  <                                                                (! (
 
 <

) 
 <                                                             $  
 <


2  
 <                                                          7  
 <


5! !<                                                              4!
 
 <


9 
 
  ! 
   41,)9 :              ,     #    -  ! <""""""""""""""""""""""""""""""
,*, 
  """"""""""""""""""""                                                  7)6 
  """"""""""""""""""""
1 
      
<
            4
   !

            %!!  
! 
 M86 
 ! !  !L
1 
      <    (! """"""""""" 1  4!J ! 
 : """""""""""""""
  M*! !!  L          (! """""""""""
                                          (! """""""""""
/ 1
 6
     
5
$ 

  
  
            '!
 16<                                 7!         + M L"""""""""

 
  
 
                                                      . !     ( 
 
                                                                         !              M-&(' ! '1,  51,L
                                                                                         *!          . !
9 !<                                        + !<                       + <



689 !<                                          + !<                       + <


/ 
 
 /
  / 

 ,

1  !
   9! !  !  !  !! 
 !   !     !
 ! 
 !  !  H 1 
! !  !       ! 
 !H ' !
 !  !
 
  !  
  9! ! !  !       !  
  !  
 ! !
 !  9! ! ! !!  
  !  H ,<  !  !  
 ! M54'L

  ! H ' 8! 
 !  N !    ! !   !H 4  
 !
  H
K6 ,!< """"""""""""""""""""""""""""""""""""""""""
K989 )
G'! P< """""""""""""""""""""""""""""""""""""" 9H P """"""""""""""""""""""""""
,!  4!! 1
< """"""""""""""""""""""""""""""""""

/0(*                                                               .  ,                                               63/.1.00'5
.  

*!   ! 
  
     
   
 ! 
 H 1 
 !  
! 
J 
 
 !! ! 
!!  ! ! !J 
 ! ! 
 
H
EH 2! 
  !   
 !  ! 
   41,)9 ! 
  :              #   ,
DH 2! 
  !   
 !  ! ! 
!  
 !  !! 
  !
   
! !  41,)9:                                                                                    #   ,
CH 2! 
  !   
 !   !    ! J   !:               #   ,
BH 2! 
  !   
 !     ! !J 
 !
 :                      #   ,
AH 6 
  !   
 ! ! ! 
!  ML  ! 
! ! ! !J
    
! ! MLJ  G!:                                                                         #   ,
@H 6 
  !   
 ! 
 ! ! !J !   !
 !
 !
   
:  #   ,
?H 1  !! !    9! .    9! .  
 !:                                 #   ,
>H (! ! 7
   ! 
     ! EF ! """""""""""""""""""""""""""""""""""
=H 1 
 
 !J   !  41,)9 J  
 ! ! !    
 &IB  &A:          #   ,


                                                       #  
 
 
                                                  + 
 
 
  
                                                        
  
' !!    ! !  ! ! J  ! !    J  !  
!!J 
  !   H 1   ! !     
      !  ! !
   
 
J ! ! !  ! J  !   
 !    
  ! !     

 
  4! 7 ) 9JEA &H(H7H E@>E   
*!  ! !  ! !  ! ! 
  
 
  
   
 
 ! !  
 !!J ! 
!J
                                                                                                                          
                                                                                                                    ! !
 ! !
! 
   !
 !    ! 
H
9! !   4! 7 ) 9J EA &H(H7H E@>E   HJ  !!!  !  4! '! 7 
  M<GGHHLH
.  
 4 )   
   

   
  
 4   
    4
 4   
 4 

  
 4 4  4  


 4 
    
 
 / (    
 
  2 )     




+ ' /
 %
& 
J 
       ! 
  ! 
J !  
 !  ! 
J  ! !
!   
  ! 
  2
' 
          
  
 ' + -
 #
 /
2

+ 
 /
 %
' 
  !  
    8
 1! 3
J *H+H 8
 ABEJ (
!J *9J E>=@@; 

 !  ! >FFID@FIE@>FH

+ -4 '
4  % /
 %
9 
      ! 
 8
 1! 3
J *H+H 8
 ABEJ (
!J *9J E>=@@H
1 !   
 
   !J 1 
! ! 1 !    !  H 1 ! !   1 
  !
 H
                              # """"""      ,""""""
                                   1!       1!
1 !  

    
 !G 
   J 1 
! ! 1 !    !  H 1 !
 !   1 
  !  H
                             # """"""      ,""""""
                                  1!      1!
K- 
< 1 
    !    
 J       MCL !       !   

  ! 
   !    ! 
    M?L !           M
 

    !    LH
/0(*                                                                  -  ,                                                        63/.1.00'5
#

  

      1   
   !  1 !  ! !  9! .H
      1    
  ! !   !    !H
      1  !    ! 
 ! 
!  9! .J  !     
   ! !    9! .H
      1   !  !   !!  J 
 ! 
!  !
 ! H 4
 

        ! ! !  !
 !  !     H
      1 ! 
 !! ! 
! ! ! !  
! !        
!  

      ! ! 1  !     
  
  !!  
! ! ! !
      
  !   !ML  1  !     H
      *
    ! !   !    9! . !    ! !  
 !
H
      9 ! ! !  
      9! .     !!  9! .   
H
      1  
! !
  9! .     !     ! !! !  !
       !  !!J ! 
! ! !
J 
   ! ! !
 H
      1 1 ! ! 
! ! 
 
       ! !  !  J 1    ! ! 1    
!!  
       !    H
      ) 
 

       4  4  4  
    
 /
4
      )       
 
 
   

  
  
   4 4 4 
      
      / (  
 
2
      ) 
 

 
 /
  
 /
 /
4 "   -4  - *  
         
 /
     / ( 
   
  
 /
4
      

 
 
 "   -  - *      
 
 /

      /
4 

 
 
 
 
  
 
4  
    
    3
      /
 /
2

( % /
 "

8 G!  <
  1 
! ! 9! .      !     !    !   
 
  !! 
 H
  1 
! ! 
 !
   ! 9! .  !    ! ! 1      !
    !H
  9 J 1 
! !    !! !  9 !   (
  J 
  
 !  !!        !!    I 9 9H
*!   ! ! 
   !!    ! I 9 9H

(!
 """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

"
  "

1   ! !  !    
 !  
 !   ! H 1 
 
! !  !
!! !    !!  
     J    
  ! !  
  9! .H ' !!   
 9! . 1
! 7! N    !  
  !
J ! ! J ! 
 9! . 1
! 7! N !!H 1 
   !   !! 
!J 1    !  !   9! . 1
! 7! N 9 G9 9J ! ! 
  J 
 
   J   !   !  9! .N !  H 9   
!
 ! !  ! ! !  !H - !
   !!   !
   ! ! 
! H ' 
J  ! ! J 
! 
!!  
 ! !
 !  ! !
  !   !! 
  ! !J 
 ! !!  !!H 1  !  ! !! !

! ! 
 
  ! !  !  J  
!!  ! 
!! 
    ;   !  ! 
 !  
  ! !J  
 !   !  ! !   !     
   !H ' 
 !   !!J ! ! J ! !      
 ! 
!!  H
8  J 1 ! !  !   9! . 7  8 *!H


/
  
 0      """""""""""""""""""""""""""""""""""""""""""""""" 6!< """""""""""""""""""""""""""""""

/0(*                                                               ,  ,                                                     63/.1.00'5
5375
                      Fargo, ND 58105
(800) 373-9807                                              2102 Great Northern Dr
                                                            Fargo, ND 58102
                                                            800.373.9807
                                                            800.293.9897 fax



                                        Letter of Intent


   This form is to notify Allianz that I intend to transfer my
      Allianz contract from my current Field Marketing
             Organization to Sunderland Group.

I, ____________________________________, hereby wish to transfer
                    (Please Print Name)



my Allianz contract to Sunderland Group FMO #10.


   _______________________________ SSN: _______________ Date: ___________
                        (Signature)




       In order to complete the transfer I understand I will need to submit a second
               letter of intent dated 6th months from the date of this request.




                                   Fax to
                                800.293.9897
                         PO Box 5375 ~ Fargo, ND 58105 ~ (800) 373-9807




                      Letter of Intent
                                   2nd Request



I, ____________________________________, hereby wish to transfer my
                     (Please Print Name)


Allianz contract to Sunderland Group FMO #010.




  ____________________________________ Date: ______________
                     (Signature)




SSN:___________________




                      Fax to
                  (800) 293-9897
                         Debit Balance & Advance Commission Agreement
                                                (Choice of Law-Arizona)
This Agreement is by and between Joseph Racich (aka Brokers Alliance, Inc.) with his principal place of
business in Maricopa County in the state of Arizona and _____________________________________, with
his/her/its principal place of business in ___________________________________________ (hereinafter called
“Agent”). This Agreement shall be applicable to every insurance company with whom the undersigned Agent is
contracted and/or appointed and Joseph Racich is the Agent’s upline.
Whereas, agent has attested in writing to Joseph Racich all current personal liens as well as debts with all
insurers, if any and agent desires to be exempt from an escrow account or bond to guarantee payment of any
future debit balance, if any and/or desires commission advancing, if eligible, from insurance companies
represented through Joseph Racich:
Now Therefore, for good and valuable consideration, the receipt and sufficiency of which is hereby
acknowledged, the parties do hereby agree as follows:
    1. Agent agrees to pay to the order of the appropriate insurance company and/or to Joseph Racich the sum
       of any indebtedness resulting from unearned advances, any remuneration, special advances, any fees,
       chargebacks of any kind, interest or any other charges to the Agent’s commission account.
    2. Within thirty (30) days written notice of demand to the agent’s last mailing address on record with
       insurance company for payment of any indebtedness to the insurance company and/or Joseph Racich,
       Agent agrees to immediately pay indebtedness in full, by cash, money order or certified funds.
    3. Agent also agrees and understands any unearned commissions and renewals are not an acceptable form
       of payment in the event demand has been made for any indebtedness. Any case involving a refund of
       premium, regardless of cause, Agent agrees to immediately remit payment, in full, to clear indebtedness.
    4. In the event an insurer holds Joseph Racich financially responsible for any Agent indebtedness or any
       other fees or monies as a result of past indebtedness and Joseph Racich finds it necessary to enforce
       payment through legal action, Agent agrees to pay reasonable legal fees and court costs incurred by
       Joseph Racich and hold Joseph Racich harmless from and against any such liability. Additionally, if it
       becomes necessary to refer this matter to a collection department, agency or result in a filing of a
       complaint to the department of insurance regarding the return of any unearned monies 35% will
       immediately be added to the principal balance.
    5. Agent agrees to assign, without contest, any commissions and renewals with other insurance companies,
       present and future, to Joseph Racich if any agent indebtedness, secured or unsecured, remains after 90-
       days of the debt occurrence. Assignments shall remain effective until all agent debts are cleared.
    6. Both parties agree the enforcement of this Agreement shall be subject to the jurisdiction of the proper
       courts of Southlake, Tarrant County, Texas and construed pursuant to the laws of the State of Texas.
This Agreement shall survive the termination of all contractual/appointment relationships between Agent and the
insurance companies represented through Joseph Racich. Agent irrevocably authorizes Joseph Racich or any
attorney of any court of record, after default, to confess a judgment without process against Agent in favor of
Joseph Racich and waives all errors in such proceedings and consents to immediate execution upon said
judgment.
This Agreement shall be a continuing one and shall remain in full force and effect until written notice from
Joseph Racich is received and until all debt and liability arising hereunder has been fully paid.
I have read the foregoing and agree to be bound by the terms and conditions set forth herein.

____________________________________________                          _______________________
            Agent Signature                                                    Date
____________________________________________________________   ______________________________________________________
             Agent Printed Name                                 Personal Guarantee Signature, if Corporation
AGREED, ACCEPTED and APPROVED by Joseph Racich in Maricopa County, Arizona.
____________________________________________________________          _______________________________
               Joseph Racich                                                   Date
Doc/Debit Balance and Advance Commission Agreement
                  COMMISSION ADVANCING SECURITY FORM
                             AUTHORIZATION TO CHARGE SUMS
                                TO CREDIT CARD/ACCOUNT


        Brokers Alliance, Inc. has agreed to guarantee the obligation(s) of the undersigned to repay

loans, advances of commissions and/or overpayment of commissions made by various

insurance companies to the undersigned. In the event at any time in the future Brokers Alliance,

Inc. pays any of the aforesaid obligations, the undersigned agrees to reimburse Brokers Alliance,

Inc. for the sums paid by Brokers Alliance, Inc. and further agrees that Brokers Alliance, Inc.

shall have the right and is hereby authorized to charge the credit cards identified below and/or

the current EFT/direct deposit checking/savings account on record for carrier contract(s) as a non-

exclusive method of receiving payment for said sums.            The undersigned acknowledges that said

sums may be charged at any time after Brokers Alliance, Inc. pays the obligation and acknowledges

that payment by Brokers Alliance, Inc. may not be made for several years after the obligation is

incurred by the undersigned. The undersigned hereby waives any statute of limitations with

regard to sums owed by the undersigned to Brokers Alliance, Inc. and agrees that, in the event

of nonpayment by the undersigned, Brokers Alliance, Inc. may report said obligation as unpaid to

any credit bureau or reporting agency.

        The undersigned agrees to immediately notify Brokers Alliance, Inc. in the event that any of

the credit cards listed below and/or the current checking/savings account on record for carrier

contract(s) are revoked, surrendered, terminated or credit is no longer available under said cards

and/or account. The undersigned further agrees to provide all updated information relative to said

credit cards immediately upon any change of information, including any replacement or

expiration of said card. In the event that the undersigned contests any charge made to any such card

and/or account and the charge is deemed valid, the undersigned shall reimburse Brokers Alliance, Inc.

for all costs and fees, including attorneys’ fees, associated with such contest.
       Because this authorization relates to an on-going guarantee of a commercial obligation, the

undersigned agrees that this authorization shall be irrevocable.



Date                                                   Signature


                                                       Printed Name


Card One (Required)

Type of Card:           □      VISA
                        □      Mastercard

Card      Number:
Expiration Date:
Security     Code:
Name on Card:
Billing Address:
Cardholder Signature:



Card Two (Required)

Type of Card:           □      VISA
                        □      Mastercard

Card      Number:
Expiration Date:
Security     Code:
Name on Card:
Billing Address:
Cardholder Signature:
- ' (  +
 %
 -
#$ , 40939
&= &% 44540<9939
199;049;2627
      ; ;




                                         
    
   
 
,  
 
 
= ( 
 

 (    
  
 
 
   )&$   
 :

  ; (  
 

  ( 
 
   )&$   
    = 
 
 )&$  ( 
 
 
 

;

 
 
 
         )  - 

                            )  '
-
   
  
? 
      
   


>


-
   -
 !! @/
                                # 
                                                                           "
 
-
    

                                                           
                                       +
                                           !

                                      

-
     -
  
                                    "
 
( 
 
      
 
=   
   
 
 
  ;

( 
 

       = < =  =  
  = (       
 


   

  
  
   = <= =  
      
 +  
 
;


-
 
   *
 


      
                              
      ) &
 $ 
 
   
 
 
  
 
 
  =   
 
 
  

    
 -
 -
   
 ) &
 $ 
 
          
  )&$= 
  
 
 - '
   (  +  %
 - 
    
        
  
 
 
  
 -

   -
=    = 
 
  
       
  
= 

  

=   

   
 
 
 
 
 
  
; ( 
    
 

      
 
      

 =
   
  
  
 
 

 .  
    

 

  
  
   = 
  
  
 
   
 

 ;

                                        
                                                  

   )&$   )&$ @
                                    # #

   )&$ 
   *
 
                                     "
 

   8; -  -
 -
  
    
    
  
 
  
    
 
   )&$  
;   

      -
 -
  
      )&$  
  
  )&$;
   7;      )&$  
     = 
    = 
  
 
    
  
       
=     =  
    
 
  : -
 -
;




&8935                                              ) 
          
   
 
                                            ?"<87:7990>
    

   
 
  %!*$*

 .  %%&%!-**$*
 #$',#$%,("&&

                                                       $!    
 . +
 &                                     . ' &                                   . ( &


 . # +'% . &

                    . . +'% . &

                   " "

 &





 
   
   
    

   "     & 
     #
  
/
        )    
 
 
    676 
:   . 
 . .
 
   
   +'% # 
8
        ! 
   

  . . .
  7          
 


        *
 $
 : 3 5 7
 4   
 . .
     

8
        !     
  
   
   . (8
        .      
  
  
  
    

 
  + '
 %
   

        ) 
   .+'%   = 

 <
     
  ;:   +'%:  .+'%:     
    
        

     
   8
        #      

 
  
   
  
  
       

 
        

   +'%8
        .  &%!       &%! 
 
  
   

 
 
   +
        '
 %
 8

&  
  %  

  &$!  
  %  
<) ;
  $!  
  %  

&  $!  
  %  
!       
 
    +'% 

 8 ) 

     

 
     
    
8

#

  
  
                 

!   
 
  /                 #7                                            # 7
   .          *
 .                          <5 
7# ;                                           <5 
7# ;
<"  
 *. 
 
  06  02;              $'
                                                            .
        . ,
                                      .
      . ,

                                                         +
 
 :  / 42726           6702
                                                         ' 
 .  
   >1:666
                                                         ' 
 .  
   >42:666
 9 
/
       &/         . &

 
       &/         . &

 
       &/         . &

 
        +'%/         +'% &

 
)   
    :        :     
  
 

  
   


8 ! +'%   :  

   
      : 
 

  
 

 

     
     

  . .
: 
  : 
 

  



      : 
  
:   
   
    

8 ! 

  
+'%  
     .+'%   
 

 

9
     


  
 

 
   
    .+'%  
    +'%  

 8 )      
  
  

   
  
 :  

     /            
  
:  

    
    8

*.  "

  - 

.+'%  "

  - 

$!  
  %  
                                                                                                                                      0-)(+(**!/

								
To top