Sole Proprietor Agent Agreement - Florida Blue - BCBSF

AGENT AGREEMENT(Sole Proprietor)This Agreement is between Florida Blue, on behalf of itself and its subsidiaries, Health Options, Inc. and FloridaCombined Life (collectively “Company”), and ___________________________________ (“Agent”) a soleproprietor having its principal place of business at _______________________________________________.Agent has read and fully understands the terms and conditions of this Agreement (the “Agreement”), and itsattachments. In signing this Agreement, Agent certifies that Agent has not been convicted of any criminal felonyinvolving dishonesty or breach of trust or been convicted of an offense under Section 1033 of the Violent CrimeControl and Law Enforcement Act of 1944. Agent further agrees to immediately inform the Company of anyconviction of the types described in the preceding sentence.To signify their agreement to the provisions of this Agreement, Company and Agent have made and entered intothis Agreement as of ________________ (“Effective Date”).Internal Use Only:Florida BlueSignature: ____________________________Print Name: ___________________________Title: ________________________________Date: ________________________________Agency:Signature: ______________________________Print Name: _____________________________TIN or SSN: ____________________________Title: __________________________________Date: __________________________________Florida Combined Life, Inc.Email: _________________________________Signature: ____________________________Print Name: __________________________Title: ________________________________Date: ________________________________Health Options, Inc.Signature: ____________________________Print Name: __________________________Title: ________________________________Date: ________________________________Please retain the rest of this contract (including this page) for your filesFlorida Blue Agent Agreement 2