Independent Producer Commission Schedule - Securian Dental

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$H:\ISPS\arpeggio reports\Directories\International ... - Securian Dental$

$H:\ISPS\arpeggio reports\Directories\International ... - Securian Dental$

Form W-9 (Rev. 11-2005) Page 4 Part II. Certification To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if items 1, 4, and 5 below indicate otherwise. For a joint account, only the person whose TIN is shown in Part I should sign (when required). Exempt recipients, see Exempt From Backup Withholding on page 2. Signature requirements. Complete the certification as indicated in 1 through 5 below. 1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification. 2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form. 3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification. 4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations). 5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification. What Name and Number To Give the Requester For this type of account: 1. Individual 2. Two or more individuals (joint account) 3. Custodian account of a minor (Uniform Gift to Minors Act) 4. a. The usual revocable savings trust (grantor is also trustee) b. So-called trust account that is not a legal or valid trust under state law 5. Sole proprietorship or single-owner LLC For this type of account: 6. Sole proprietorship or single-owner LLC 7. A valid trust, estate, or pension trust 8. Corporate or LLC electing corporate status on Form 8832 9. Association, club, religious, charitable, educational, or other tax-exempt organization 10. Partnership or multi-member LLC 11. A broker or registered nominee 12. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments 1 Give name and SSN of: The individual The actual owner of the account or, if combined funds, the first individual on the account 1 The minor 2 The grantor-trustee 1 The actual owner 1 The owner 3 Give name and EIN of: The owner 3 Legal entity 4 The corporation The organization The partnership The broker or nominee The public entity List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished. 2 Circle the minor’s name and furnish the minor’s SSN. 3 You must show your individual name and you may also enter your business or “DBA” name on the second name line. You may use either your SSN or EIN (if you have one). If you are a sole proprietor, IRS encourages you to use your SSN. 4 List first and circle the name of the legal trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules regarding partnerships on page 1. Note. If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S. possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
Assignment of Commissions Securian Life Insurance Company AGENT NUMBER: (designated by Securian Life) NAME OF ASSIGNOR (Agent/Producer) TELEPHONE NO. NAME OF ASSIGNEE ASSIGNEE'S FED. TAX I.D. NO. ADDRESS OF ASSIGNEE (Street, City, State, Zip) TELEPHONE NO. For and in consideration of one dollar and other good and valuable considerations, the receipt and sufficiency of which are hereby admitted by the Assignor, the Assignor does hereby assign, transfer, and set over unto the Assignee all of the Assignor’s right, title, and interest in and to any and all commissions due or to become due the Assignor under the above‐described Contract. The receipt by the Assignee of amounts paid in accordance herewith shall release and discharge Securian Life of and from all liability therefore. Amounts assigned hereby shall not be payable hereunder unless and until they become due and payable under the terms of the Contract. It is understood that Securian Life, by consenting to this assignment, shall not be held to waive its rights to offset at any time against any amounts due under the Contract the amount of any debts owed by the Assignor to Securian Life or to any applicant for dental insurance in Securian Life, irrespective of when such debts are incurred; nor shall Securian Life be held to waive any claims which it may otherwise have under the Contract. Extension or postponement of time of payment of any debt due at any time from the Assignor to Securian Life shall not prejudice the rights of Securian Life. ASSIGNOR EFFECTIVE DATE OF ASSIGNMENT SIGNATURE OF WITNESS SIGNATURE OF ASSIGNOR SECURIAN LIFE DATE OF SIGNATURE SIGNATURE OF AUTHORIZED OFFICER Securian Dental is underwritten by Securian Life Insurance Company and administered by DeCare Dental Health International, LLC In California, Securian Dental is underwritten by Securian Life Insurance Company, offered through DeCare Dental Insurance Services, LLC and administered by DDHI Administrators, LLC. Securian Agent Appointments •730 South Broadway • Gilbert, MN 55741 Toll‐free 1‐866‐201‐1818 Option 1 • Fax 877.631.8953 • Securian_Commission@SecurianDental.com www.SecurianDental.com Form: - SDCOMM-2 REV 7-2011
Page 1 and 2: Securian Independent Producer Appoi
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Page 5 and 6: eturns on terminated Policies; (3)
Page 7 and 8: IN WITNESS WHEREOF, you and, by the
Page 9 and 10: HIPAA BUSINESS ASSOCIATE ADDENDUM T
Page 11 and 12: mutually agreed upon period of time
Page 13 and 14: 4.6 Indemnity. Business Associate w
Page 15 and 16: Any fee for providing such electron
Page 17 and 18: Independent Producer Data Sheet Sec
Page 19 and 20: Form W-9 Request for Taxpayer (Rev.
Page 21: Form W-9 (Rev. 11-2005) Page 3 Gene
Page 25: Commission Reports User Request For

Independent Producer Commission Schedule - Securian Dental

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