NOITAMROFNI LANOSREPemaN lluF htriB fo etaD ecalphtriB

oN esneciL s'revirD ytiruceS laicoS :sraeY loohcS hgiH gniniarT sllikS egelloC

sserddA emoH ytnuoC emiT fo htgneL emoH gniyuB gnitneR

)( enohP emoH )( enohP lleC sserddA remroF

reyolpmE tsaP noitisoP etatS ,ytiC morF oT

TNEMTNIOPPA TNEGA LIAB ROF NOITACILPPA T AS:CARTNOC AIV

UFC-0124 (5/12)

62494 IM ,ELLIVNOSDUH ,EVIRD OGACIHC 41230644-266-616 xaF enohP

Non-Liable Sub Agent Employee Solicitor

NOITAMROFNI TNEMTNIOPPA DNA ESNECIL ).sdnob tsop ot nalp uoy erehw seitnuoc eht thgilhgih esaelP .etats ruoy fo pam a desolcne evah eW(

:esneciL liaB tnerruC - oN .noitamrofnI yrotalugeR ot eunitnoc dna noitces siht dragersid esaelP .oN esneciL - seY etatS etaD evitceffE etaD noitaripxE dna lawener esnecil ,sserdda fo egnahc tuoba wal etats htiw tnerruc peek esaelP .lawener hcae retfa dna won ypoc a dnes esaelP .sdnob liab gnitirw eunitnoc dna tnemtnioppA ruoy niatniam ot tnerruc eb tsum esneciL ruoY .noitacude gniunitnoc

?ynapmoc ecnarusni na htiw tnemtnioppA na evah uoy oD oN ?)setats emos yb deriuqer( dnoB liviC a evah uoy oDseY oN ?ecrof ni " tcartnoC etepmoC oN" a evah uoy oDseY oN seY

Appointment: tnerruCsetaD ynapmoC ecnarusnI

/ / / /

General Agent

- If “yes” to above, have you been granted consent (“1033 waiver”) from any insurance regulatory official to engage in the business of insurance?

- NOITAMROFNI YROTALUGER seinapmoc ecnarusni dloh dna eriuqer snoitaluger ecnarusni ro/dna wal laredef dna etats esuaceb deksa gnieb era snoitseuq esehT .seetnioppA rieht fo noitagitsevni hguoroht eht rof elbisnopser

Do you currently have a felony case pending against you? oN seY gnidnep esac a evah yltnerruc ro ,detcivnoc neeb reve uoy evaH tcudnoc larom reporpmi ro ytsenohsid gnivlovni ronaemedsiM a rof ? oN seY

?ycnegA ruoy ro uoy rof esneciL a detanimret ro ,tsniaga enif a dessessa ,dednepsus ,desufer reve ecnarusnI fo tnemtrapeD a saH oN seY tirw detanimret ro dednepsus ,desufer reve ffirehS ro truoC a saH tiefrof diapnu na fo esuaceb ro ,tcudnocsim rof segelivirp gni ?ycnega ruoy ro uoy rof eru oN seY

hsnoitaler ro tcartnoC liaB a dah reve ycnega ruoy ro uoy evaH laretalloc reporpmi ,smuimerp timer ot eruliaf rof detanimret pi ?ytivitca lagelli ro gnildnah oN seY rpersim fo snoitagella gnivlovni gnideecorp laiciffo ro tiuswal yna ni elbail dnuof neeb reve uoy evah ro ,devlovni won uoy erA ?sdnuf fo noitairporppasim ro duarf ,noitatnese oN seY

?troppuS dlihC yap ot redrO truoC a rednu yltnerruc uoy erA oN ?tnerruc stnemyap troppuS dlihC ruoy era ,os fI - seY oN seY ?tneuqniled neeb reve yeht evah ro ,won tneuqniled sexat lanosrep ro ssenisub lacol ro etats ,laredef ruoy erA oN seY

?yctpurknaB gnilif ni devlovni yltnerruc uoy era ro ,yctpurknaB delif reve uoy evaH oN seY OPSID LANIF DNA NEPO FI SUTATS GNIWOHS ,NOITATNEMUCOD LAICIFFO ETELPMOC HCATTA ESAELP "SEY" DEREWSNA ERA EVOBA SNOITSEUQ YNA FI . DESOLC FI ,NOITIS

a state or federal felony which prohibits you under the Violent Crime Control and Law Enforcement Act of 1994 from engaging in the business of insurance? fo detcivnoc neeb reve uoy evaH oN seY oN seY

*** ***

:NOITAMROFNIESAELEROTNOITAZIROHTUADNANOITACIFITRECTNACILPPA tnegA liaB a sa tnemtnioppa rof gniylppa fo esoprup cificeps eht rof noitamrofni siht gnidivorp ma I

er I noitacifiton yna sedulcni sihT .setailiffa sti dna ,ynapmoC inrecnoc laiciffo truoc ro etats ,laredef a morf yltcerid eviec I .segelivirp gnitirw ro/dna esnecil liab ym fo noitacover ro noisnepsus ,erusnec eht gn

erutangiS tnacilppA dengiS etaD

Insurance Company to obtain on the nature and scope of such an investigation. I hereby authorize Universal Fire & Casulaty Insurance Company, its affiliates and third party vendors to obtain information from any and all relevant sources with regard to my financial and fiduciary responsibilities (including any credit reporting agency), past and present employment, business practices, license and appointment histories, insurance transactions, real estate and property holdings, criminal and judicial records, private business records including medical reports and any other information that may reflect upon my reliability, character, work habits, ethics and ability to effectively represent Universal Fire & Casualty Insurance Company and its affiliates. I authorize Universal Fire & Casualty Insurance Company and its representatives to share this information with other individuals or companies who are participating in my appointment process or tenure, or future appointment in the insurance industry. I hereby authorize any person or entity requested to furnish the above information to Universal Fire & Casualty Insurance Company and its affiliated representatives, upon the presentation of this document in its original form, in a photocopy or facsimile version.

authorized to post Surety Bail Bonds, in the Courts of my licensed states(s), on behalf of Universal Fire & Casualty Insurane Company. I hereby certify that I am making application to be insurance licensed, or

understand that investigative inquiries can be conducted now or anytime during the tenure of this appointment. I acknowledge my right to make a reasonable written request to Universal Fire & Casualty

in this application and attachments is true and complete. Should I be appointed, I understand that it is my obligation to keep this information accurate and up-to-date, with Universal Fire & Casualty Insurance

understand that I am also obligated to make immediate and full disclosure concerning any criminal or misdemeanor charges that should be brought against me, during the course of my company appointment. I

that I am currently licensed for this line of business and that license is compliant and in good standing with all Department of Insurance licensing rules and regulations. I further certify that all information submitted

800-874-8742