4. Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

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. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

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 for Part II, later.

 

The undersigned (“Member”) hereby accepts the invitation to become a member of the Horizon Retailers Association (“HRA” or “Association”), and said Membership shall become effective upon Member’s execution and delivery of this agreement to the Association without variance and its counter execution by the Association.

Member consents, represents and acknowledges the following: Membership is hereby acquired solely for the purpose of enabling Member to participate in the united and collective efforts of the Association through associations, negotiations and purchase of goods and services from vendors; Membership is not being acquired as an investment of any kind; Membership has no economic value in and of itself; Member shall not derive any economic benefit from becoming a Member other than Member’s own efforts and participation in programs afforded them through Association; member is not obligated to participate in any program the Association has provided from vendors or service providers; Association is not responsible for any non-payment from vendors; Association relies solely on data provided by vendors; Association is not liable to make any payment for any store that is not a current member; Association may provide basic information to vendors and prospective vendors in order for vendors to contact Member concerning any available programs, however Association will not sell Member’s information to anyone; Member is not a member of another similar collective; Association is not responsible nor liable for any false applications; Association is not responsible nor liable for any disputes between Member and vendors, however, Association may attempt to assist Member in the event of any such dispute; Member must comply with product and space requirements in all programs they participate in; Member is not required to advertise and promote any program, but may do so in their discretion; unless Member uses its assigned account number for all vendors, Member shall not receive any benefit of any kind of programs with the Association; other than as provided in this agreement, Member shall be responsible to determine whether a vendor is a participant in any program with Association; Association is entitled to the exclusive possession of all other revenue streams without any right or interest of the Member; this agreement may terminated by either Member or Association at any time, for any reason upon thirty days notice to the other; this agreement is subject to change at the discretion of Association, at any time, and Member acknowledges, consents and agrees to any such changes by continuing as a Member subsequent to any change; Member shall not disclose the terms of this agreement nor any of Member’s/Association’s information containing pricing, rebates, incentives, allowances or concessions; this agreement shall remain in effect for the calendar year in which Membership becomes effective and shall automatically renew each year thereafter unless terminated as set forth hereinabove.

Association shall issue member an account number when this Membership becomes effective. To participate in any programs, Member must use its account number in all dealings with Association and the manufacturers, and manufacturers’ vendors or providers of products and services.

Member hereby names and appoints Association as its exclusive representative and agent to apply for, manage and receive all rebates, incentives, allowances and concessions which Member receives or is entitled to from manufacturers, vendors or providers of the products or services offered by the Association, and from which Member makes purchases using its Association account number. In consideration of the Association’s services, Member authorizes and directs the Association to receive and be paid fifteen (15%) of all rebates, incentives, allowances and concessions received in connection with this agreement. The remainder of all rebates, incentives, allowances and concessions received by Association shall be paid to the Member for the program(s) participated in by the Member, at such intervals determined solely by the Association, but no less than annually.

Member warrants and represents that it is a retailer, properly licensed and qualified to do business in this state and that if Member is a retailer at more than one place of business, Member must maintain a separate Membership and separate Association Membership number for each business location.

    

Felonious Assault Program

Statistically, there are over 35,000 convenience store robberies each year. Store owners face the horrible reality of a store employee being injured or killed. Workers’ Compensation pays expenses such as medical for injuries and a percentage of salary if an employee is killed. In most cases, Workers’ Compensation is not enough!!

Breeden Benefit Group have created a Felonious Assault Program for the benefit of HRA Members. The program will cover owners and employees. If death occurs during a Felonious Assault, the plan will pay the family up to $400,000. If an injury occurs during a Felonious Assault, the plan will pay up to $2,500 per month while in the hospital and up to $385 weekly while recovering. 

This program was created for convenience store associations throughout the United States. Over $18,000,000 in financial relief has been paid to families. A family member cannot be replaced, however $400,000 will assist with future expenses.

Felonious Assault	$400,000 (directed at the member’s business, property or while he/she is acting on behalf of the business)
Hospital Daily Benefit	$2,500 monthly (2 day minimum. Monthly benefit will be paid retroactive to the first day of confinement)
Weekly Disability	$385/weekly (7 day waiting period, maximum 26 weeks as long as the insured remains disabled due to injury)
Bereavement & Trauma	$150/per session (10 sessions within one year of the date of the incident)
Wheelchair Confinement	Up to $50,000 (for expenses incurred within one year of the date of incident)

FREQUENTLY ASKED QUESTIONS

How much is my premium? $56.25 per quarter = $18.75 per month.

How do I pay? Premiums will be automatically deducted from your quarterly rebate check.

When is this insurance effective? Coverage will begin at the beginning of the next quarter of your HRA enrollment. Ex) If you became a member of HRA on 8/24/2021 then your coverage would begin on 10/1/2021. Beginning dates: January 1st, April 1st, July 1st, October 1st.

What happens if I do not opt out? Your coverage will automatically begin and premium will be deducted from your rebate check or you have two months to receive a 100% refund.

How do I opt out? Complete the form on the back of this page or on following link: www.hraga.com/bbg

Is there a limit on how many employees are covered? No, All part time and full-time employees are covered (no cash employees). $400,000 coverage per employee with a per incident limit of $800,000. Example: If three employees are killed, the $800,000 would be divided by three.

DISCLAIMER

This policy is subject to change at any time. The insurance company may change the terms and conditions of this policy, including the rates, benefits, and exclusions. Coverage under this policy is not guaranteed. The insurance company may deny coverage to any applicant or policyholder for any reason, including the citizenship of the injured party. HRA is not the provider of the insurance policy described above. HRA is not liable for any damages arising from the denial of coverage, including but not limited to lost wages, medical expenses, and emotional distress. Any and all claims under this policy shall be made directly to Breeden Benefit Group. HRA recommends that all Members communicate with a commercial insurance company to make sure that Member has adequate insurance coverage for its business. Should the insurance company increase premiums, HRA shall have the right to deduct additional funds from the Member’s rebate without providing notice. The insurance policy is governed by the laws of the state in which the insurance company is licensed to operate.

 

Contact Information

Darrell Breeden
512.495.9799
darrell@breedenbenefitsgroup.com

 

 

Your company agrees to accept payment from HRA and its subsidiaries and affiliates (“HRA”), by electronic funds transfer (“EFT”) and further represents and warrants that the information supplied to HRA on this enrollment form is true, complete and accurate. The following terms and conditions are incorporated into and amend any and all existing agreements with HRA relating to electronic payment. Should any of the terms or conditions contained herein conflict with terms or conditions contained in other agreements between your company and HRA relating to electronic payment, the terms of this agreement shall control.

HRA will initiate payment to you based on the following:

1. The electronic funds transfer will be made to the financial institution and account number listed on this enrollment form.

2. We will make payments in accordance with and be governed by the National Automated Clearinghouse Association’s Corporation Trade Payment Rules. This process is governed by and in accordance with the laws of New York.

3. The information on this form is very important. You understand that any change in the information must be communicated by an authorized representative of your company in writing to HRA in time to allow HRA to respond to the change. You expressly agree to indemnify and hold harmless HRA, from any loss that may arise by reason of error, mistake or fraud relating to the information you have provided.

4. Payment is initiated within the normal terms of our commercial arrangement with you. Except as noted above in the case of conflicting terms, HRA EFT terms and conditions do not modify our respective rights and obligations under any applicable agreement. HRA will consider payment made when your financial institution has received or has control of the payment transaction. This will generally occur within two (2) business days following initiation by HRA.

If HRA initiates payment on a non-Banking Day at HRA originating bank, the funds transfer will occur the following Banking Day. Banking Day is defined as the day on which both trading partners’ banks will be available to transmit and receive these funds transfers.

5. HRA has the right to adjust future payments if payments made are found to be duplicates, in excess of requirements, fraudulently induced, or otherwise in error.

6. HRA is responsible for payment to the point your financial institution receives or has control of the transaction. You assume responsibility for making arrangements with your financial institution to notify you upon receipt of payment. Any loss from or after that point will be borne by you unless the loss is due to the sole negligence of HRA or its originating bank.

You should notify HRA immediately if payment is not received as described in item 4 (above).

7. This authorization shall remain in effect until such time as either party terminates EFT by providing the written notice not less than ten (10) business days prior to the proposed termination date.