4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):
(Applies to accounts maintained outside the U.S
5 Address (number, street, and apt. or suite no See instructions.
Taxpayer Identification Number (TIN)
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)thatI 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.
Request for Taxpayer Identification Number and Certification
Go to www.irs.gov/FormW9 for instructions and the latest information.
Give Form to the requester. Do not send to the IRS.
Buffalo Health Advisors LLC
This AGENT AGREEMENT (“Agreement”) is made and entered Date by and among Buffalo Health Advisors, LLC (“BHA LLC”) and First Name Last Name (“Agent”). WHEREAS, Insurance Company (“Plan”) is licensed to operate and is engaged in the business of providing insurance services to groups and or individuals.WHEREAS, Agent (“Agent”) is an insurance agent or sales representative who possess all requisite permits, licenses and other approvals issued by the Department of Insurance of the applicable states in which BHA LLC operates, or other applicable state regulatory agencies to sell life and health insurance benefit plans.I. Appointment. Upon required background and licenser verifications, and completion of BHA LLC requirements for appointment, Agent shall hereby be authorized by BHA LLC to solicit applications for life and health insurance plans offered by BHA LLC subject to the terms and conditions set forth in this Agreement. It is agreed by the Agent that such appointment includes no provision for any exclusive territorial representation by Agent.II. Relationship. The relationship of Agent to BHA LLC shall be construed as that of an independent contractor. The relationship of Agent to BHA LLC shall not be construed to create the relationship of employer and employee. Agent shall be free to exercise his own judgment and discretion as to the persons solicited and the time and place of solicitation.III. Authority. Agent is hereby authorized to solicit and prepare applications for policies of life and health insurance plans from acceptable groups or individuals, subject to the following provisions. These provisions are all encompassing to include all products approved by BHA LLC, current and future. Some provisions may not be applicable to all products. The provisions are:a. Territory. Applications for coverage may be solicited only within the approved service area in which BHA LLC is authorized to do business and only for products approved by BHA LLC, the applicable state Department of Insurance, and or the Centers for Medicare and Medicaid Services (CMS) where applicable.b. Limitations. When applicable, the Agent is not authorized to:1. Make, alter or discharge the provisions of any policy;2. Bind BHA LLC or Plan by making any promise or by accepting any representation or information not contained in the application for coverage;3. Quote premiums, rate or policy values other than those published by the Plan;4. Extend the time of payment of any premium or extend the date of the grace period for payment in the policy;5. Collect and/or deposit any premium or payment except the first month’s premium;6. Broadcast, publish or distribute any advertisements or other materials referring to BHA LLC or Plan, not originated by BHA LLC or Plan, or which is not BHA LLC’s or Plan’s most current advertisement or other materialproduced or published by BHA LLC or Plan without first securing BHA LLC’s approval in writing. Agent shall defend and indemnify BHA LLC and hold BHA LLC harmless from all acts incurred in any connection thereafter, whether or not well founded, which may be alleged against BHA LLC and which arose directly or indirectly as a result of any unauthorized action, misuse of advertisements or materials produced by BHA LLC, or statements or misstatements of Agent; and7. Voluntarily make any payment, assume any liability or incur any expense on BHA LLC’s behalf, except at Agent’s own expense, without the prior written consent of BHA LLC. IV. Responsibilities. With the authority granted herein, Agent and BHA LLC agree to accept the following responsibilities:a. Representation and Service. Agent agrees to:1. Represent the provisions and benefits of each policy of coverage adequately and fairly to prospects at time of solicitation in accordance with applicable State and Federal laws and regulations.2. Use best efforts to provide service to policyholders in a prudent, conscientious and businesslike manner consistent with the highest standards of honesty and integrity and to maintain and promote the relationship between the Plan and members.3. Observe and comply with the rules and regulations of BHA LLC as well as any applicable State and Federal laws now in force or hereafter promulgated pertaining to the conduct of business covered by this Agreement, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), it being understood that such rules and regulations will not interfere with the freedom of action of Agent as previously described;4. Comply with BHA LLC’s policies regarding the use of confidential information.b. Records and Examinations. Agent and BHA LLC agree to keep complete and accurate records of all transactions connected with the business covered by this Agreement and to make such records available for examination by an authorized representative of BHA LLC or Agent at any time before or following termination of this Agreement.c. License; Insurance. Agent and BHA LLC shall, at all times during the term of this agreement, be licensed by the applicable state Department of Insurance as an insurance agent/sales representative. Agent and BHA LLC shall both have and maintain Errors and Omissions insurance and such other insurance as may be required and acceptable to BHA LLC as described in Appendix A, Section 1. G.d. Disciplinary Proceedings. Agent shall promptly notify BHA LLC and Plan of the institution of any disciplinary proceeding relating to the license issued to Agent.
1. Agent and BHA LLC agree that Agent must be approved, certified and continually re-certified by Plan and/or such other agency and/or organization which BHA LLC, at its sole discretion, deems necessary andproper to conduct this certification prior to commencing sales. BHA LLC, at its sole discretion, may immediately relieve Agent from marketing product(s) on behalf of BHA LLC upon written notice to Agent by BHA LLC.2. Agent must receive designated training by BHA LLC or its representative.f. Policies and Procedures. Agent agrees to abide by the Policies and Procedures as established by BHA LLC and shall be required to abide by such Policies and Procedures. BHA LLC shall make best efforts to notify Agent of changes in the BHA LLC’s Policies and Procedures within 30 day of said changes.
a. Commissions. Commissions, if processed by BHA LLC, shall be computed and paid in accordance with the rates and provisions set forth in the current year’s commission schedule. BHA LLC may deduct and offset any debt due from Agent to BHA LLC.b. Vesting. BHA LLC provides immediate vesting for Agent on all lines of insurance business.c. Renewals. BHA LLC will pay Agent continued annual and/or monthly commission renewals based upon the individual contract of product for the life of the policy as defined by the carrier.d. Legal Proceedings. Agent shall not institute legal proceedings of any kind or character on behalf of BHA LLC or any policyholder in connection with any matter pertaining to business covered by this Agreement. Agent agrees to promptly notify BHA LLC, in writing, of the institution of any legal proceedings against Agent in connection with the business covered by this Agreement. Furthermore, Agent and BHA LLC agree to indemnify and hold the other harmless from any judgments, settlements, attorney fees or other expenses resulting from any unauthorized, negligent or unlawful acts, omissions or statements by Agent or BHA LLC.e. Property. All books, contracts, records, rate manuals, advertisement materials, enrollment forms, applications, ID cards, supplies, leads, etc. furnished by BHA LLC to Agent shall remain the property of BHA LLC and shall be immediately returned upon demand or termination of this Agreement.f. Policy and Compensation Changes. Upon written notice to Agent, BHA LLC shall have the right at any time to:1. Discontinue or withdraw approval to sell any type of policy in any of its service areas;2. Introduce new types of policies and determine the rate of commission payable thereon. VI. Term and Termination. Term and termination are set forth in Appendix A, Section E.
VII.Applicable Law. Any question or law concerning the validity, construction, interpretation, administration or effect of this Agreement shall be governed in accordance with the laws of the State of Tennessee.
VIII. Assignment. The interest of Agent in this Agreement and all rights hereunder, including specifically Agent’s right to receive commissions, is not assignable without the prior written consent of BHA LLC.IX. Amendment. No provision of this Agreement may be amended, modified or otherwise altered unless in writing and executed by Agent and an authorized officer of BHA LLC. X. Severability. If any provision of this Agreement or portion thereof is declared invalid or unenforceable, the remaining provisions shall nevertheless remain in full force and effect. XI. Entire Agreement. This Agreement is the entire agreement between the parties and supersedes and voids any previous agreements between the parties. This Agreement, together with all Appendices attached hereto or made a part hereof, shall constitute the entire agreement between Agent and BHA LLC. IN WITNESS WHEREOF, this Agreement has been entered into by the parties the day and year first written above.
COMMISSION TERMS AND CONDITIONS
Agent’s commission shall be vested immediately for all business produced through BHA LLC.
In all possible circumstances, commissions will be paid to Agent directly by the Plan. In the event the Plan requires BHA LLC to process and pay commissions on business submitted by Agent, commissions shall be calculated as per schedule in Appendix B.
BHA LLC shall make an appropriate adjustment in Agent’s commission upon discovery of a clerical error. This includes BHA LLC’s right to collect reimbursement from future commissions due to Agent for any overpayment.
Amounts payable hereunder may not exceed any maximum prescribed by any federal or state law, regulations or legal ruling.
This Agreement is effective as of the day and year first above written and shall continue until terminated by either party. This agreement may be terminated:ï Voluntarily and immediately, by either Agent or BHA LLC upon written or verbal notice of the terminating party’s intent to terminate this Agreement.ï In the event of voluntary termination under this section, any commissions due to Agent shall continue to be payable to Agent as long as commissions are paid by the Plan.ï Immediately and at the discretion of the BHA LLC, in the event Agent materially breaches the terms or conditions of this Agreement, fails to comply with BHA LLC’s Policy and Procedures, intentionally violates any compliance, regulatory, or ethical provisions, causes imminent harm to the reputation of BHA LLC or its ability to conduct business in its service areas or future service areas, fraud or malfeasance, or ceases to be a qualified and duly licensed insurance agent or Agent under applicable rules and regulations of the applicable state and Agent’s right to any compensation hereunder shall automatically terminate.Additionally, Appendix B must be signed on an annual basis to ensure Agent’s receival of updated commission schedule.
Agent is responsible for and will provide assurance and proof to BHA LLC that the appropriate and applicable licenses and Errors & Omissions coverage are in effect, including all applicable renewal certifications, which allow Agent to legally sell and promote health and life insurance products. Agent must provide appropriate documentation upon request from BHA LLC.
Agent is responsible for and will provide assurance and proof to BHA LLC that the appropriate and applicable Errors & Omissions coverage are in effect. Minimum specific coverage of$1,000,000 with an aggregate minimum of $1,000,000.
BHA LLC, when possible, defers the payment of Agent commission to the Plan. In some instances, the Plan will require BHA LLC to process and pay commissions. In this event, commissions will be paid according to the schedule outlined in Appendix B.
BHA LLC will pay commissions every two weeks. Commissions will be paid to Agent based on what has been paid to BHA LLC and received on behalf of the Agent. BHA LLC will not advance any unearned commissions.
Renewals on sales produced by Agent will be paid to the appropriate entity as directed by the Agent by this agreement.Renewal payments will commence in the thirteenth (13th) month of continuous membership in the insurance plan and will be paid as earned on a monthly basis. Renewals will continue for the life of the policy. Payment will be in the pay period following the date of receipt.
Commissions are based on a member’s continued enrollment in the insurance plan. Early termination from the insurance plan can result in a chargeback of unearned commissions. In the event a commission was processed to Agent by BHA LLC and the Plan recaptures the earned commissions paid by BHA LLC to the Agent, a commission chargeback will occur. The chargeback will be equal to the commissions already paid to the Agent by BHA LLC. BHA LLC will rely on the accounting methods provided by the Plan, but will have authority to question such actions by the Plan if deemed necessary by BHA LLC.
If Agent wishes for commissions be paid to a business or entity other than the person named on this contract, please specify by noting below.I hereby state that it is my wish for my commissions earned while under this contract to be paid to:Entity: Entity Name Address: Street Address Address Line 2 City State Zip Tax ID:
Signed: Signature Date: Date
Agent Non-Disclosure and Confidentiality Agreement
This Agent Non-Disclosure and Confidentiality Agreement (this “Agreement”) is made and entered into on the Date between Buffalo Health Advisors, LLC (“the company”), an entity organized and existing under the laws of the State of Tennessee, with its head office located at 624 Grassmere Park Drive, Suite 1, Nashville, TN 37211; and First Name Last Name (“Agent”). The above parties may be referred to singularly as a “Party” or collectively as the “Parties”. In consideration of the Agent’s Independent Contractor Agreement by the Company and the covenants and mutual promises contained herein, the Parties agree as follows:
IN WITNESS WHEREOF, the parties have executed this Agreement, effective as of the date set forth herein. AGENT: First Name Last Name Signature