Assurity Life Insurance Company

1526 K Street • PO Box 82533

Lincoln, NE 68501-2533
Toll Free 800-276-7619

License Appointment Checklist

The procedure for licensing agents differs in each state. All states, however, are uniform in requiring that an agent be
properly licensed before soliciting insurance sales. Assurity supports this position and requests your complete
compliance with the licensing laws of your state(s). Please review the Appointment Guidelines for Business Received
(reverse side) for more information.
You must return all of the following items completed in full to Contracting at Assurity. Information should be
typed or printed legibly. Missing items will delay the contracting and appointment process.

Appointment Application
When appointing an agency, you must include both the tax identification number and social security
number on the Appointment Application.
** The e-mail address and other information provided is confidential and will be used for Assurity
business purposes only. E-mail addresses are requested to facilitate communication between you and
the company and/or its affiliates. E-mail addresses are not sold or furnished to any other entity except as
may be required by law or regulatory authority.
Agreement
Sign, date and return the Agreement and Commission Schedule.
Authorization for the Release of Information
Authorization Agreement for Automatic Deposits
W-9 Form
All potential agents must complete and submit a W-9 form. If we are paying commissions to your agency,
the W-9 must be completed with agency information and tax identification number.
Copies of Licenses
Current copies of your resident and non-resident licenses for all states where you or your agency need to
be appointed must be attached. If commissions are to be paid to your agency, send a current copy of the
agency license along with the copy of your license.
Non-Resident Appointment Fees
Refer to the Non-Resident Appointment Information form for fee information. Fees for all states where
you need a non-resident appointment must be included. Make your check payable to Assurity Life
Insurance Company.
Credit Card Authorization
If you would like to charge your appointment fees to your credit card, complete and sign the Credit
Card Authorization form and send in with other forms.

NOTE: In doing business with Assurity, you will need to access our extranet site to obtain your commission
statements and production reports as Assurity does not mail any commissions or production reports.
You will receive more information about this once you have become contracted and appointed with
Assurity.

04-052-05005 (03/06)
 801P
Assurity Life Insurance Company
1526 K Street • PO Box 82533
Lincoln, NE 68501-2533
Phone: 800-276-7619

Appointment Application
COMPLETION INSTRUCTIONS
Individual Applicants: Complete sections I, III, IV, V & VI. Must sign and return applicable contracts.
Corporations: Complete sections I, II, III, IV, V & VI. All Corporate appointments require that appointment information be submitted on
at least one officer concurrent with the Corporation. Must sign and return applicable contracts for agency and Solicitor contracts for
officer.
Solicitor Applicants: Complete sections I, II, III, IV, V & VI. Must sign and return Solicitor contracts.
PLEASE PRINT OR TYPE AND RESPOND TO ALL QUESTIONS. DO NOT USE ABBREVIATIONS.
I. GENERAL INFORMATION
Mr. Mrs. Ms. Miss Name _____________________________________________________________________________
Maiden or other name
Social Security # (If applicable) ___________________________________________
Residence
Address___________________________________________ Residence Phone ( ________) ______________________________

City _____________________ ST________ Zip___________ Business Phone ( ________) ______________________________

Business
Address __________________________________________ Fax Number ( ________) _____________________________

City _____________________ ST________ Zip___________ Date of Birth _____________________________________________

Email
[email protected]
Address* __________________________________________ Gender (Optional) M F
** The e-mail address and other information provided is confidential and will be used for Assurity business purposes only. E-mail
addresses are requested to facilitate communication between you and the company and/or its affiliates. E-mail addresses are not sold
or furnished to any other entity except as may be required by law or regulatory authority.
Primary mailing address to receive Company Information including Underwriting and Compensation correspondence
Business Address Residence Address
II. AGENCY INFORMATION
Agency Name ________________________________________________________________________________________________

Corporation Partnership Tax I.D. # _________________________________________

List officers and their titles below:

Name Soc. Sec. #

Name Soc. Sec. #

III. ASSIGNMENT OF COMMISSIONS (Select one option)

Paid Direct: The commission check is made payable and sent to the agent.
Agency Direct/Solicitor: The commission check is made payable and sent to the Agency listed in Section II.

Agent’s Signature Date

IV. LICENSES
You must include current license copies for each state in which you are requesting an appointment. If you are requesting
non-resident appointments, you must include the proper appointment fee(s).
Current Resident License # ___________________________ State(s) for Appointment ___________________________________

**If requesting non-resident Florida appointment, list all counties where appointment is required

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 801P
V. ERRORS AND OMISSIONS COVERAGE
All Assurity producers must maintain a minimum coverage of $500,000 for each claim per agent with a maximum $10,000 deductible.

Do you have Errors and Omissions Coverage? Yes No

Please provide the carrier for your Errors and Omissions coverage, the policy number and the name of the insured.

VI. QUALIFICATION QUESTIONS

1) Have you lived in a different state or county than your present one within the last 5 years? Yes No
If Yes, please list state/county
2) Have you ever been convicted for any offense or pleaded guilty to any misdemeanor or
felony charges or have charges currently pending against you or a business with which
you are connected?.................................................................................................... Yes No
3) Do you currently have a pending bankruptcy or have you ever filed for bankruptcy, been
declared bankrupt or insolvent, had your salary garnished?....................................... Yes No
4) Are you at the present involved in any litigation or are there any unsatisfied judgments or
liens (including state or federal tax liens) against you?............................................... Yes No
5) Have you ever had a bond denied, paid out or revoked? ........................................... Yes No
6) Has any insurance company canceled any contract with you or appointment of you as a
sales person for any reason other than non-production of business or at your own
request? .................................................................................................................... Yes No
7) Are you indebted to any Insurance Company/Agency/Manager (including debit balance)? Yes No
8) Have you ever had any complaints against your conduct that resulted in a return of
premium to any insured? ........................................................................................... Yes No
9) Have you ever been fined, suspended, placed on probation, reprimanded, entered into a
consent order by any insurance department, the SEC, or any other regulatory authority? Yes No
10) Have you ever had an insurance and/or securities license refused/suspended/revoked or
currently restricted or under investigation by any insurance department, the SEC, or any
other regulatory authority?.......................................................................................... Yes No
11) How many years have you been licensed as an insurance agent? ____________
12) How many companies are you currently contracted with? ____________________
You must attach details and dates for any questions answered Yes above.

I hereby certify that the statements contained in this Appointment Application are true and correct to the best of my knowledge and
belief. I understand that any false statements on this Application may be considered as sufficient cause for rejection of this Application,
or for termination if such false statement is discovered subsequently.
I understand and agree that:
I can solicit business only in states where I am licensed and appointed with Assurity Life Insurance Company.
I will not solicit business in states that prohibit solicitation prior to my appointment.
As a general rule, it is not acceptable to make a solicitation anywhere other than the resident state of the applicant.
I will abide by all written rules and regulations (subject to change at any time) set forth by the Company.

Agent’s Signature Date _____________________

THIS BOX MUST BE COMPLETED

WHO IS YOUR RECRUITING AGENT? AGENT ID

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 ASSURITY LIFE INSURANCE COMPANY
1526 K Street • PO Box 82533
Lincoln, NE 68501-2533
Toll Free 800-276-7619

AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS

(1) I (we) hereby authorize the Company to initiate credit entries to my (our)
checking savings account in the entity named below (“Depository Institution”),
and I (we) authorize the Depository Institution to accept and to credit the amount of such
entries to my (our) account. Such authorization does not allow the Company to debit entries
to my (our) account.

(2) DEPOSITORY INSTITUTION:

(3) CITY: STATE: ZIP:
(4) BANK ROUTING NO.: ACCOUNT NO.:

This authority is to remain in full force and effect until Company has received written notification
from me (or either of us) of its termination in such time and in such manner as to afford
Company a reasonable opportunity to act on it and in no event shall it be effective with respect
to entries processed by the Company prior to receipt of notice of termination.

The undersigned hereby agree(s) that all entries initiated hereunder are to be governed in all
respects by the Rules of the National Automated Clearing House Association and agree(s) to be
bound thereby.
(5) AGENT’S NAME (please print):
(6) AGENT’S ID NO. (if known):
(7) DATE: SIGNED:

Notes for completing form:

(1) – Indicate if checking or savings account;
(2) – through (5) – Complete all information;
(6) – If new agent, leave blank; otherwise complete
(7) – Date and sign.

Please fill out this form and mail to the address shown above, Attn: Contracting, or fax to
402-437-4640.

Please confirm that your Routing number and Account number are correct.

04-023-05005 (08/04)
 801P
ASSURITY LIFE INSURANCE COMPANY
1526 K Street • PO Box 82533
Lincoln, NE 68501-2533
Toll Free 800-276-7619

Disclosure and Authorization for Consumer Reports

DISCLOSURE
In connection with your application for contract services with Assurity Life Insurance Company, a consumer report or an investigative consumer
report will be requested during the application process and if contracted, during your contract term. It may contain information about your character,
general reputation, personal characteristics, mode of living, qualifications and credentials. The nature and scope of the consumer report or
investigative consumer report is the procurement of reports such as consumer credit, criminal records, civil records, driving records, employment
verification, education verification, professional license verification and others. I understand that, upon written request within a reasonable period of
time, I am entitled to additional information concerning the nature and scope of this investigation. I understand that pursuant to the Fair Credit
Reporting Act (FCRA), I have the right to know if adverse action is being considered against me as a result of information contained in this report,
that I have the right to a copy of this report prior to any adverse action taken against me and to dispute the accuracy of any information in this report
by contacting the consumer reporting agency. I understand that I may have additional rights under state law which I may determine by contacting my
state or local consumer protection agency.

Consumer Reporting Agency: Business Information Group

PO Box 130
Southhampton, PA 18966
(215) 396-9870

Oklahoma, Minnesota, and California applicants may obtain a copy of this consumer report by checking this box. This report will be sent to
California applicants within three (3) days of the employer receiving the report.

California applicants only: For consumer reports which were not obtained by a consumer reporting agency, by checking this box you waive
the right to obtain a copy of the report. If unchecked, you will receive this report within 7 days of the employer receiving it.

California only: For reports obtained by Business Information Group, California applicants also may review the file Business Information Group
maintains on you during normal business hours, upon submitting proper I.D. and by paying fees associated with making copies of those files. In the
State of California, a new Disclosure and Authorization/Release of Information form is required each time a subsequent Consumer
Report/Investigative Consumer Report is going to be requested. The nature and scope of the consumer report or investigative consume report is the
procurement of reports such as consumer credit, criminal records, civil records, driving records, employment verification, education verification,
professional license verification and others.

AUTHORIZATION / RELEASE OF INFORMATION

I have carefully read and understand the above Disclosure. I hereby authorize the obtaining of driving records, consumer reports and investigative
consumer reports at any time after receipt of this authorization. I authorize without reservation, any party or agency contact by Assurity Life
Insurance Company, to furnish information about my character, reputation, personal characteristics, credentials, and/or credit and indebtedness. I
understand this may involve obtaining driving records, personal interviews with sources such as schools, employers, supervisors, friends, neighbors,
associates, state, federal or local agencies, and public record or law enforcement agencies. I further authorize ongoing procurement of these reports
at any time during my continued employment or contract for services, unless specifically prohibited by state law. I also agree that a fax or photocopy
of this authorization with my signature shall be accepted with the same authority as the original.
I further understand and authorize by signing below, that in accordance with the legitimate business practices of Assurity Life Insurance Company
that copies of my application and consumer reports may be furnished to the affiliates, assignees or agents of Assurity Life Insurance Company.

Signature ________________________________________________________________________ Date ________________________

mm/dd/yyyy

IDENTIFICATION INFORMATION FOR CONSUMER REPORTING AGENCY

Name _____________________________________ Date of Birth _________________ Social Security # ___________________
First / MI / Last (Please Print or Type) mm/dd/yyyy

04-022-05005 (02/06)
 INVESTIGATIVE CONSUMER REPORTING AGENCIES ACT
California Civil Code Section 1786.22

(a) An Investigative Consumer Reporting Agency shall supply files and information required
under Section 1786.10 during normal business hours and on reasonable notice.

(b) Files maintained on a consumer shall be made available for the consumer’s visual
inspection, as follows:

(1) In person, if he appears in person and furnishes proper identification. A copy of

his file shall also be available to the consumer for a fee not to exceed the actual
costs of duplication services provided.

(2) By certified mail, if he makes a written request, with proper identification, for
copies to be sent to a specified addressee. Investigative Consumer Reporting
Agencies complying with requests for certified mailings under this section shall
not be liable for disclosures to third parties caused by mishandling of mail after
such mailings leave the investigative consumer reporting agencies

(3) A summary of all information contained in files on a consumer and required to be

provided by Section 1786.10 shall be provided by telephone, if the consumer has
made a written request, with proper identification for telephone disclosure, and
the toll charge, if any, for the telephone call is prepaid by or charged directly to
the consumer.

(c) The term “proper identification” as used in subdivision (b) shall mean that information
generally deemed sufficient to identify a person. Such information includes documents
such as valid driver’s license, social security account number, military identification card,
and credit cards. Only if the consumer is unable to reasonably identify themselves with
the information described above, may an Investigative Consumer Reporting Agency
require additional information concerning the consumer’s employment and personal or
family history in order to verify his identity

(d) The Investigative Consumer Reporting Agency shall provide trained personnel to explain
to the consumer any information furnished them pursuant to Section 1786.10.

(e) The Investigative Consumer Reporting Agency shall provide a written explanation of any
coded information contained in files maintained on a consumer. This written explanation
shall be distributed whenever a file is provided to a consumer for visual inspection as
required under Section 1786.22.

(f) The consumer shall be permitted to be accompanied by one other person of their
choosing, who shall furnish reasonable identification. An Investigative Consumer
Reporting Agency may require the consumer to furnish a written statement granting
permission to the consumer reporting agency to discuss the consumer’s file in such
person’s presence.

04-022-05005 (02/06)
*Complete only if submitting non-
resident license(s) or if requesting
re-appointment with Assurity. ASSURITY LIFE INSURANCE COMPANY
1526 K Street • PO Box 82533
Lincoln, NE 68501-2533
Toll Free 800-276-7619 Fax 402-437-4640

CREDIT CARD AUTHORIZATION

I authorize Assurity Life Insurance Company to charge the credit card listed below in the amount of
for the contracting appointment fees for which I am applying today.
I ACKNOWLEDGE:
1. USE OF THE CREDIT CARD FOR PAYMENT IS OPTIONAL;
2. THIS AUTHORIZATION DOES NOT COVER THE CHARGING OF FUTURE FEES;
3. THIS CHARGE WILL BE INITIATED ONLY WHEN THE ACCOMPANYING APPLICATION(S) IS (ARE)
ACCEPTED

Name on Card Mastercard

Card/Account Number Visa
Expiration Date
Discover
Billing Address
! Please Note: Debit
City State Zip cards may only be used
to pay for contracting
Phone Number appointment fees if the
card shows the
Signature Mastercard or Visa logo.

Date of Signature

04-048-05005 (05/05)
Form
(Rev. January 2005)
W-9 Request for Taxpayer Give form to the
requester. Do not
Department of the Treasury
Identification Number and Certification send to the IRS.
Internal Revenue Service
Name (as shown on your income tax return)
See Specific Instructions on page 2.

Business name, if different from above

Print or type

Individual/ Exempt from backup

Check appropriate box: Sole proprietor Corporation Partnership Other © withholding
Address (number, street, and apt. or suite no.) Requester’s name and address (optional)

City, state, and ZIP code

List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid Social security number
backup withholding. 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 3. 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 3. or
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number Employer identification number
to enter. –
Part II 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 4.)

Sign Signature of
Here U.S. person © Date ©

Purpose of Form
A person who is required to file an information return with the ● Any estate (other than a foreign estate) or trust. See
IRS, must obtain your correct taxpayer identification number Regulations sections 301.7701-6(a) and 7(a) for additional
(TIN) to report, for example, income paid to you, real estate information.
transactions, mortgage interest you paid, acquisition or Foreign person. If you are a foreign person, do not use
abandonment of secured property, cancellation of debt, or Form W-9. Instead, use the appropriate Form W-8 (see
contributions you made to an IRA. Publication 515, Withholding of Tax on Nonresident Aliens
U.S. person. Use Form W-9 only if you are a U.S. person and Foreign Entities).
(including a resident alien), to provide your correct TIN to the Nonresident alien who becomes a resident alien.
person requesting it (the requester) and, when applicable, to: Generally, only a nonresident alien individual may use the
1. Certify that the TIN you are giving is correct (or you are terms of a tax treaty to reduce or eliminate U.S. tax on
waiting for a number to be issued), certain types of income. However, most tax treaties contain a
provision known as a “saving clause.” Exceptions specified
2. Certify that you are not subject to backup withholding, in the saving clause may permit an exemption from tax to
or continue for certain types of income even after the recipient
3. Claim exemption from backup withholding if you are a has otherwise become a U.S. resident alien for tax purposes.
U.S. exempt payee.
Note. If a requester gives you a form other than Form W-9 to If you are a U.S. resident alien who is relying on an
request your TIN, you must use the requester’s form if it is exception contained in the saving clause of a tax treaty to
substantially similar to this Form W-9. claim an exemption from U.S. tax on certain types of income,
you must attach a statement to Form W-9 that specifies the
For federal tax purposes you are considered a person if you following five items:
are: 1. The treaty country. Generally, this must be the same
● An individual who is a citizen or resident of the United treaty under which you claimed exemption from tax as a
States, nonresident alien.
● A partnership, corporation, company, or association 2. The treaty article addressing the income.
created or organized in the United States or under the laws
3. The article number (or location) in the tax treaty that
of the United States, or
contains the saving clause and its exceptions.
Cat. No. 10231X Form W-9 (Rev. 1-2005)
 ®
ASSURITY LIFE INSURANCE COMPANY
AGENT AGREEMENT

Accepted: ASSURITY LIFE INSURANCE COMPANY

This Agreement is effective .

By: Signature of Agent or Firm Principal

Approved:

Print or Type Name and Title Here Company Officer

This Agreement is between the Agent who signed this Agreement (referred to as “you,” “your,” and/or “Agent” in this Agreement) and Assurity Life
Insurance Company (we will be referred to as “Assurity,” “our,” “we,” “us,” and “the Company”). The provisions stated in all supplements,
commission rules, and schedule of commissions are incorporated into and made a part of this Agreement. This Agreement shall become effective
on the date shown above.

1. AUTHORITY
You are appointed to represent Assurity in the state(s) in which you maintain proper license and/or appointment and the Company is duly licensed.
You hereby accept such appointment and agree to comply with this Agreement as well as all operating, financial and underwriting guidelines, rules
and regulations of the Company and the laws and regulations of the state(s) in which you operate. You are authorized to act as an agent on behalf
of Assurity for the purpose of developing and supervising the distribution of Assurity’s insurance products. Specifically, you are authorized to: 1)
recruit and recommend persons for appointment by Assurity, 2) train and supervise such agents in accordance with Assurity’s business rules and
the requirements of the state(s) in which they are licensed and in which they act as an agent for Assurity, and 3) solicit applications for the
insurance policies written by Assurity and approved for marketing..
2. RELATIONSHIP
You are an independent contractor and nothing in this or any other agreement between you and the Company shall be construed to create the
relationship of employee or employer between you and the Company.
You are free to exercise your own judgment in determining when, how and to whom you sell Assurity policies. You choose the time, place and
manner of sale, but you are to conform to state law and regulation and our rules and instructions that are not inconsistent with the independent
contractor relationship.
You also acknowledge that all agents in your hierarchy are independent contractors of Assurity and, at a subagent’s election or for good cause, can
be transferred by Assurity according to Assurity’s transfer rules.
3. DUTIES
You are required to follow certain guidelines while exercising the authority granted under this Agreement. These guidelines include, but are not
limited to, the following:
a. For any applications solicited by you, you may also collect the first premium. You shall submit applications and first premiums immediately
to Assurity.
b. Service and help us keep in force the policies you sell for the Company.
c. Segregate any monies you receive for us and hold them in trust until delivery. You shall not use such funds for any purpose.
d. You shall notify Assurity immediately upon becoming aware of any felony convictions relating to you or any agent in your hierarchy.
e. You shall comply with Assurity’s policies and procedures concerning the replacement of life, health and annuity contracts. A replacement
occurs whenever an existing policy or contract is terminated, converted, or otherwise changed in value. You shall recommend the
replacement only when replacement is in the best interest of the customer. You shall fully disclose any and all relevant information to the
customer regarding the financial impact to the customer of the replacement, whether a new contestability period and/or suicide clause will
start under the new policy (if applicable), and whether the customer will have to resubmit to underwriting to purchase the new policy. You
agree never to recommend that a customer cancel an existing policy until a new policy is in force, and the customer has determined that the
new policy is acceptable.
f. You agree to adhere to Assurity’s rules concerning ethical market conduct which require you to:
i. carefully evaluate the insurance needs and financial objectives of your clients, and use sales tools (e.g. sales brochures and policy
proposals and/or illustrations) to determine that the insurance or annuity you are proposing meets these needs;
ii. maintain a current license and valid appointment in all states in which you promote the sale of Assurity products to customers and
keep current of changes in insurance laws and regulations by reviewing the bulletins and newsletters published by the state insurance
departments and Assurity;
iii. comply with Assurity’s policies concerning replacements, and refrain from providing false or misleading information about a competitor
or competing product or otherwise making disparaging remarks about a competitor;
iv. submit, prior to use, all advertising materials intended to promote the sale of Assurity products to us for approval;
v. immediately report to us any customer complaints, and assist us in resolving the complaint to the satisfaction of all parties; and
vi. communicate these standards to any agent in your hierarchy and request their agreement to be bound by these conditions as well.

4. LIMITATIONS OF AUTHORITY
You do not have authority to and you shall not:
a. Interfere with any person’s business relationship with the Company.
b. Accept risks, incur debt or liability, or make contracts in our name or on our behalf.
c. Promise reinstatement of any policy or coverage, or commit Assurity to any action regarding any claim.
d. Waive, alter, modify or change any Company policy, terms, rates or customary requirements.
e. Deliver policies except in accordance with our instructions.
f. Start legal actions in our name.

04-199-05005 (08/07) 1
 c. Waive, alter, modify or change any Company policy, terms, rates or customary requirements.
d. Deliver policies except in accordance with our instructions.
e. Start legal actions in our name.
f. Extend credit to applicants or insureds, personally pay any applicant’s or insured’s premiums, or allow extra time to pay a premium.
g. Collect any premium other than the initial premium unless we authorize it.
h. Endorse checks or any negotiable instrument payable to or intended for the Company.
i. Deliver any policy when you or your agents have knowledge of any impairment of the applicant’s health either not disclosed on the
application or that occurred subsequent to the securing of the application.

5. COMPENSATION
Your compensation shall be based on your personal production and the production of all agents assigned to you. You will receive payments as
shown in the Commission Schedule (“Schedule”), as amended from time to time, for premiums received on policies issued by the Company for
applications secured under this Agreement. Commissions will be paid according to the Commission Schedule that is in effect on the written date on
the policy application. The Schedule states the required repayments of compensation for lapsed, terminated, or surrendered policies. We can
change the Schedule, but any change will not affect business applied for prior to the effective date of the change. Payment of compensation will be
made at such times and in any manner as we determine. You must access our web site to obtain commission statements and production reports.
You must object to any transactions shown on EFT statements and compensation reports within 30 days of receiving them, or they will be deemed
to be conclusive.

Your right to commissions shall be deemed fully vested, and except as specifically limited to herein, the renewal commissions shall be paid for the
term and in the amount shown in the Schedule, so long as they exceed $250 in a year, or you are receiving first year commissions. Vesting will
cease if this Agreement is terminated for cause. If this Agreement terminates because you die, we will continue payments to your designated
beneficiary. If no beneficiary is designated, we will pay your executor. Payments after your death will cease if the policyholder requests a new
agent.
You authorize us to provide your production and earnings records to the Agent(s), if any, to whom you are assigned.

6. GENERAL PROVISIONS
a. Errors and Omissions Coverage. For as long as this Agreement is in force, you shall maintain Errors and Omissions insurance with a
carrier in amounts and with a deductible that we accept. You agree to provide evidence that such coverage is in force upon our request for
such evidence.
b. Personal Liability. You agree to indemnify us and hold us harmless from all losses and expenses we incur resulting from your acts or
omissions other than those which we so authorize in writing.
c. Advertising. You shall comply with our advertising rules. You shall not use, permit, or cause to be used, our name or any advertising
regarding our products without obtaining our prior written consent.
d. Expenses. You agree to be solely responsible for all your expenses incurred in performing this Agreement.
e. Indebtedness. Any amount you or your subagents owe us is a first lien on any compensation payable to you under this Agreement until the
debt is fully paid. You agree that if at any time you have a debit balance with us, you are not due any compensation. Commissions will be
credited to your account until such time as the debit balance has been cleared. Termination of this Agreement does not release you from
continuing liability to us for immediate repayment of any debt including unearned first year commissions or bonuses. We have the right to
charge interest at the maximum lawful rate on any outstanding debt.
f. Return of Premium. If, for any reason, we refund premiums on which you received compensation, you agree to immediately repay us any
compensation you received on that premium.
g. Waiver. Failure of the Company to strictly enforce any provision of this Agreement will not be interpreted as a waiver of such provision.
h. Modification. Any change to this Agreement must be in writing signed by an authorized officer of the Company.
i. Assurity Property. You agree to return all of our property upon demand or at this Agreement’s termination. Our property includes, without
limitation, all rate books, manuals, supplies, applications, video materials, computer software, insured files and advertising and sales
materials supplied by the Company and not owned by you.
j. Assignment. You cannot assign this Agreement or compensation payable hereunder unless we agree in writing in advance.
k. Governing Law. This Agreement is governed by and interpreted according to Nebraska law. All actions with respect to this Agreement shall
be brought in a court of competent jurisdiction in Lancaster County, Nebraska.
l. Entire Agreement. This Agreement including any attachments, schedules and addendums, supersedes any and all previous Agreements
between you and the Company, and is the entire Agreement between you and the Company. If any provision of the Agreement is now or
shall in the future be in conflict with any applicable law or any valid Department of Insurance ruling or order, it shall be modified to the extent
necessary for compliance.
m. Privacy. You agree to protect any confidential information of the Company’s customers that is accessible by you. Confidential Information
includes, but is not limited to any nonpublic personal information about the Company’s customers or potential customers, regardless of
whether it is personally identifiable or anonymous information. You agree, now and at all times in the future, not to use or disclose
Confidential Information to any person or entity, other than to carry out the purposes for which the Company’s applicant or customer
disclosed the information, or as necessary to carry out the lawful business purposes of this Agreement, or as otherwise allowed by law or
regulation. Your use or disclosure of Confidential Information shall comply at all times with federal and state privacy laws, rules and
regulations.
n. Anti-Money Laundering. You agree to comply with all applicable anti-money laundering laws, regulations, rules and government
guidance, including the reporting, record-keeping and compliance requirements of the Bank Secrecy Act (“BSA”), as amended
by the USA PATRIOT Act (the “Patriot Act”). These Acts include requirements to identify and report currency transactions and
suspicious activity, to implement a customer identification program to verify the identity of customers and to implement an anti-
money laundering compliance program.

7. TERMINATION
Either party may terminate this Agreement at any time by giving written notice. Notice may be mailed or delivered to the last known address of the
other party. If you reside in, or are licensed in, a state that requires advance notice, you hereby agree to waive any advance notice of termination
and agree that termination will be effective immediately upon delivery of written notice. We may terminate this Agreement for cause if you commit
any act that injures our business or reputation; fail to account for and remit promptly any monies collected by you for us; or withhold any policies,
money or other property belonging or returnable to the Company.

04-199-05005 (02/06) 2
 ASSURITY LIFE INSURANCE COMPANY 801P
ANNUALIZATION ADVANCE AGREEMENT
This Annualization Advance Agreement is an addendum to the Agent Agreement between Assurity Life Insurance Company (“Assurity”) and the Agent named below (“you”)
(the “Agent Agreement”).
I select the following option for payment of my advanced (annualized) commissions from Assurity Life Insurance Company.
Check one: Check one:
Daily payment* 50%
Semi-monthly payment (15th and last day of each month) 75%
100%
It is understood and agreed as follows:
1. If you selected to receive daily advances, you must utilize direct deposit.* If you elect to have your advanced commissions paid daily but do not utilize direct deposit,
Assurity will continue to pay your advanced commissions on a semi-monthly basis.
2. The daily payment will not apply to any business written prior to the effective date or to any pending business currently in Assurity’s Home Office.
3. While this Agreement remains in effect, Assurity will advance to you annualized first year base and non-base commissions on policy forms that are deemed in Assurity’s
sole discretion to be advanceable. This Agreement applies only to policies issued with a monthly premium mode.
4. Assurity will advance 50%, 75%, or, 100% of your annualized first year base and non-base commissions. This percentage may be changed no more often than every six
months. The maximum amount of first year commission that will be annualized on any one policy is $3500 per agent. One hundred percent (100%) of the earned
commission on each of the policy’s premiums will be applied to offset this debt, until it is paid in full. Thereafter, commissions will be payable as earned under and subject
to the terms of your Agent Agreement.
5. An advance will be made when the policy is issued and the initial premium is received by Assurity. In the event of any rescission, lapsed, cancelled or surrendered policy,
or death of the insured, any unearned portion of the advance will be deducted from the next advance(s) and any earned first year or renewal commission. For any
subsequent reinstatement, commission will be paid as earned. If there is any debt remaining at month-end because of the rescission, lapsed, cancelled, or surrendered
policy, or insured’s death, Assurity may, at its discretion, require you to remit payment in full to clear such debt.
6. The outstanding balance of advances made to you shall be a debt that you owe to Assurity, and Assurity shall have a first lien against all monies that any division of
Assurity may owe you from time to time to secure that debt, including any interest payable as provided below.
7. If this Agreement or your Agent Agreement is terminated for any reason, the debt you then owe Assurity under this Agreement shall become due and payable
immediately, and you shall pay us interest at 6% per annum on any balance remaining unpaid thereafter. In addition to any other remedies Assurity may have, Assurity
may retain any monies we owe you or that become owing to you, immediately and without notice or resort to judicial process.
8. In addition to any debt under this Agreement, including interest, you agree to pay Assurity all costs and reasonable fees (including attorneys fees) and costs of collection
that Assurity incurs to effect payment of your debt, which will become part of that debt.
9. This Agreement may be terminated at any time with or without cause, by either party, by giving notice to the other in writing at the last known address. This Agreement
will terminate automatically upon and at the same time as termination of your Agent Agreement.
10. If you are a partnership or corporation, each individual signing below on your behalf shall be jointly and severally liable for any debt hereunder and shall be subject to the
lien provided above and enforcement of it on the same basis and to the same extent as you.
11. This is the entire agreement between you and Assurity as to advances of annualized first year base and non-base commissions, and it amends your Agent Agreement
only as and to the extent stated. Assurity may, at its sole discretion, modify the terms of this Agreement at any time. Any change in this Agreement may be made only in
writing signed by Assurity.
12. This Agreement is signed for Assurity at its Home Office in Lincoln, Nebraska and shall be subject to and construed under the laws of the State of Nebraska. All actions
with respect hereto shall be brought in a court of competent jurisdiction in the State of Nebraska.
13. The provisions of paragraphs 6, 7, 8, and 9 will survive the termination of this Agreement.
Dated this day of , 20 .

Agent Signature Social Security Number

Agent Printed Name

MANAGING AGENT(S) AS GUARANTOR(S)
Each managing agent accepts responsibility as a Guarantor, and agrees to be jointly and severally liable for any debts of the agent signing the above Agreement. Each
managing agent agrees that such a debt will be a first lien against any money owed by any division of Assurity to managing agent.

By: By:
National Marketing Organization (NMO) Brokerage General Agent (BGA)

NMO’s Printed Name BGA’s Printed Name

By: By:
Managing General Agent (MGA) General Agent (GA)

MGA’s Printed Name GA’s Printed Name

ASSURITY LIFE INSURANCE COMPANY
This Agreement is effective for policy applications written on or after .
Date
By:
Officer

04-171-05005 (05/05)