Gerber Life Insurance Company

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Contract Checklist for General Agent (Corporation w/Special Agent)Name: ______________________________________________________________________REQUIRED DOCUMENTS FOR CONTRACTINGGeneral Agent Agreemento Signature Page Signed & Datedo Full Name Printed or Typedo Tax Identification Number Section Completedo Certification Section Completed, Signed & Datedo Return Signature Page OnlySpecial Agent Agreemento Signature Page Signed & Datedo Full Name Printed or Typedo Tax Identification Number Section Completedo Certification Section Completed, Signed & Dated by the Principalo Return Signature Page OnlyBackground & Information Sheeto Personal Section Completedo Business Section Completedo Background Experience Questions 1 and 2 Answeredo Answering “YES” to either question requires a written, signed and dated explanation.o Signed & DatedFair Credit Reporting Act Disclosureo Signed & DatedCheck Deposit Authorization (Optional)o Completed, Signed & Datedo Voided Check or Deposit Slip AttachedCurrent State LicensesALL States in Which General Agent Will Be Soliciting Business.NOTE: For contracted entities who will not sell, solicit, negotiate or hold themselves out as an insurance agency, nolicense is required except in the following states:Corporations:Individuals:GA MA MT NM PA UT PR VAGA KS MA MT NM PA UT PR VAPLEASE NOTEALL MATERIALS MUST BE RETURNED TO YOUR MASTERGENERAL AGENCY TO CONTINUE THE CONTRACTING PROCESSMaster General Agency: Transmittal Form(s) must accompany all General Agent contractingpaperwork.<strong>Gerber</strong>_Corp_Checklist 10-2011
General Agent_______________________________________________Sign Name (required)_________________________________________________Print Name_________________________________________________Title_________________________________________________General Agent_________________________________________________Date_________________________________________________Designated BeneficiaryTaxpayer Identification Number (TIN)Enter your TIN in the appropriate box. For individuals, this is your social security number. For other entities, it is youremployer identification number.Social Security NumberOR Employer Identification NumberCertificationUnder penalties of perjury, I certify that:A. The number provided is my correct taxpayer identification number, andB. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have notbeen notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of afailure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backupwithholding, andC. I am a U.S. person (a U.S. citizen or U.S. resident alien or a partnership, corporation, company or associationcreated or organized in the U.S. or under the laws of the U.S. or an estate (other than a foreign estate) or adomestic trust (as defined in Regulations section 301.7701-7)).Certification instructions: You must cross out item 2 above if you have been notified by the IRS that you arecurrently subject to backup withholding because you have failed to report all interest and dividends on your taxreturn.The Internal Revenue Service does not require your consent to any provision of this document other than theabove-referenced certifications required to avoid backup withholding.SignHereSignature ofU.S. person Date 10-2011 6 BMO02G.002
Page 1: Gerber Life Insurance CompanyLicens
Page 5 and 6: BACKGROUND AND INFORMATION SHEETNam
Page 7: Direct Deposit AuthorizationI, the

Gerber Life Insurance Company

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