This completed application must be received and approved by USA-ASSIST prior to payment of commissions to any entity or individual. Both Agency and agent must be licensed in their State(s) of operation before receiving payment of commission.

USA-ASSIST will be unable to process commissions without this completed application and appropriate State(s) licensing information.

I authorize USA-ASSIST to contact the Insurance Department or the Corresponding Regulatory Entity regarding this application to verify the license status.

I authorize the release of commission payments to the licensed person or entity indicated in Section 1, and further agree to indemnify and hold USA-ASSIST, affiliates and/or their insurance carriers harmless from any liability resulting from or arising out of any payments made in accordance with the commission payment to the person or entity named in Section 1 above.

If approved, I agree to comply with and be bound by all of the guidelines, rules, bulletins, or other written instructions issued by USA-ASSIST, now in force or as they may be hereafter promulgated, amended or supplemented and all applicable laws and regulations of any insurance department or other government authorities having jurisdiction over USA-ASSIST, its carriers or any subject matter of any contract.

Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further certify under penalties of perjury that:

• I am the beneficial owner (or I am authorized to sign for the beneficial owner) of all the income to which this form relates,

• 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) that I 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

Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or any withholding agent that can disburse or make payments of the income of which I am the beneficial owner.