Direct Benefits

AGENT APPOINTMENT CHECKLIST

APPOINTMENT PAPERWORK CONSISTS OF:

o Agent Personal History Record – Please complete and sign

o Signed Group Commission Schedule

o W-9 for Income Reporting – Complete and sign

o Independent Broker Agreement

o Signed Electronic Funds Transfer (EFT) – if you wish to have your Commission checks Automatically Deposited to your Checking Account. Please sign and return and make sure to attach a Voided Copy of Check.

o Citizens Security Life Ins. Co. Privacy Policy Addendum

o Copy of “Current” License for the Agent and for the Agency, if paying Commissions to a Tax ID#. Please send a copy of the license for each state to be appointed.

ALL THE ABOVE MUST BE SUBMITTED IN
ORDER TO BE APPOINTED

PLEASE RETURN ALL APPOINTMENT AND CONTRACTING INFORMATION TO:

DIRECT BENEFITS, INC.
325 CEDAR STREET, SUITE 800
ST. PAUL, MN 55101
PHONE: 800.620.5010 FAX: 651.649.3502
ATTN: TRACEY HAGEMEIER
TRACEY@DIRECTBENEFITS.COM

IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT TRACEY HAGEMEIER AT 651.259.6244

National Guardian Life Insurance Company is not affiliated with the Guardi an Life Insurance.

CITIZENS SECURITY LIFE INSURANCE COMPANY
PO BOX 436149 . LOUISVILLE, KY . 40253-6149
Phone: 800-843-7752 Fax: 502-254-4065
www.citizensgroup.com

For Office Use Only:
______________________________
______________________________

AGENT PERSONAL HISTORY RECORD This form must be completed by applicants for Insurance Agents Licenses or prospective appointees. It will be made a permanent part of your Home Office file. Please type or print your answers and return this form to our office
Lastname:	Firstname:	Middle	Maiden


Social Security No.:		Birthdate:

Street:		Phone :

City:		State:	Zip Code:

Email:		Cell No.:	Fax No.:

BUSINESS
Name :		Tax ID :

Street :		Phone No. :

City:		State :	Zip Code :

Commissions are to be paid to (please check one) : Agent Agency / Corporation
License #(if business is currently licensed):


In which states do you want to be appointed?


Please give previous employer (within last five years)

Have you previously been an agent for Citizens Security? Yes No

If Yes and you know your Agent#, please

AUTHORIZATION
I understand that until my appointment is processed and in my possession I may not offer or sell any policies of this company. As part of the normal procedures of appointing Agent or General Agent, an investigative consumer report may be obtained in accordance with your Authorization. This may include information obtained through personal interviews with you, your neighbors, your friends and others with whom you are acquainted, as to your character and general reputation

AUTHORIZATION
Agent/ Broker Signature:			Date: 06 02 2012

AG - 8 REV 02/2012

GROUP AGENT
COMMISSION SCHEDULE

This group commission schedule and the associated renewal requirements shall be in effect for all groups with effective dates after July 31, 2006 and supersedes all previous group commission schedules.

GROUP LIFE, DENTAL, AND VISION
EMPLOYER PAID OR VOLUNTARY

STANDARD 10% LEVEL* First Year
RENEWAL 7% LEVEL Renewal Years

*May not be applicable to some negotiated groups with separate commission agreements.

RENEWAL

Renewal commissions for Group business are payable as long as the Writing Agent satisfies all of the following requirements:

1. Remains appointed with Citizens Security.

2. Remains licensed with the appropriate states DOI.

3. Continues to service the group; service shall be defined as responding in a timely fashion to requests from the Group Administrator, or other appropriate representative of the Group, relative to claims, billing matters, adding or removing employees from the group coverage, and other typical and appropriate concerns relative to group coverage; in determining whether service to the group has been adequate, the opinion of the Group Administrator, or other appropriate representative of the Group, shall be given substantial weight to the extent it is not arbitrary


Accepted by:
Date:06 02 2012
AG - 47

Form W-9 ( Rev . November 2005 ) Department of the Treasury Internal Revenue Service	Request for Taxpayer Identification Number and Certification	Give form to the requester. Do not send to the IRS.

Name (as shown on your income tax return)

Business name, if different from above

Check appropriate box: Individual / Sole Proprietor Corporation Partnership Other

Exempt from backup withholding

Address (number, street, and apt. or suite no.)

City, state, and ZIP code

Requester's name and address (optional)

List account number(s) here (optional)

Part I

Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.

Social Security No

or

Employee Identification No

Part II

Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

2. 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

3. I am a U.S. person (including a U.S. resident alien).

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and


Sign Here	Signature of U.S person:	Date : 02 /06 /2012

Purpose of Form

A person who is required to file an information return with the IRS, must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA.

U.S. person. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to:

1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt payee. In 3 above, if applicable, you are also certifying that as a U.S.person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income. Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9.

For federal tax purposes, you are considered a person if you are:

The U.S. grantor or other owner of a grantor trust and not the trust, and

The U.S. trust (other than a grantor trust) and not the beneficiaries of the trust. Foreign person. If you are a foreign person, do not use Form W-9. Instead, use the appropriate Form W-8 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). Nonresident alien who becomes a resident alien.

Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a ''saving clause. Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the recipient has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items:

1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.
2. The treaty article addressing the income.
3.The article number (or location) in the tax treaty that contains the saving clause and its exceptions.
4.The type and amount of income that qualifies for the exemption from tax.
5.Sufficient facts to justify the exemption from tax under the terms of the treaty article. Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.

If you are a nonresident alien or a foreign entity not subject to backup withholding, give the requester the appropriate completed Form W-8.
What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 28% of such payments (after December 31, 2002). This is called ''backup withholding. Payments that may be subject to backup withholding include interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.

Payments you receive will be subject to backup withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the Part II instructions on page 4 for d Generally, individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends.
Note. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding.

Exempt payees. Backup withholding is not required on any payments made to the following payees:

1. An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2),
2. The United States or any of its agencies or instrumentalities,
3. A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities,
4. A foreign government or any of its political subdivisions, agencies, or instrumentalities, or
5. An international organization or any of its agencies or instrumentalities.Other payees that may be exempt from backup withholding include: 6. A corporation,
7. A foreign central bank of issue,
8. A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States,
9. A futures commission merchant registered with the Commodity Futures Trading Commission,
10. A real estate investment trust,
11. An entity registered at all times during the tax year under the Investment Company Act of 1940,
12. A common trust fund operated by a bank under section 584(a),
13. A financial institution,
14. A middleman known in the investment community as a nominee or custodian, or
15. A trust exempt from tax under section 664 or described in section 4947. The chart below shows types of payments that may be exempt from backup withholding. The chart applies to the exempt recipients listed above, 1 through

15.IF the payment is for . . . THEN the payment is exempt for . . . Interest and dividend payments All exempt recipients except for 9 Broker transactions Exempt recipients 1 through 13. Also, a person registered under the Investment Advisers Act of 1940 who regularly acts as a broker Barter exchange transactions and patronage dividends Exempt recipients 1 through 5 Payments over $600 required to be reported and direct sales over $5,000 1 Generally, exempt recipients 1 through 7 2

1 See Form 1099-MISC, Miscellaneous Income, and its instructions. 2 However, the following payments made to a corporation (including gross proceeds paid to an attorney under section 6045(f), even if the attorney is a corporation) and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees; and payments for services paid by a federal executive agency.

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.

3. The IRS tells the requester that you furnished an incorrect TIN,

4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or

5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See the instructions below and the separate Instructions for the Requester of Form W-9.

Also see Special rules regarding partnerships on page 1.

Penalties

Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.

Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.

Specific Instructions Name

If you are an individual, you must generally enter the name shown on your income tax return. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name.

If the account is in joint names, list first, and then circle, the name of the person or entity whose number you entered in Part I of the form.

Sole proprietor. Enter your individual name as shown on your income tax return on the ''Name line. You may enter your business, trade, or ''doing business as (DBA) name on the ''Business name line.

Limited liability company (LLC). If you are a single-member LLC (including a foreign LLC with a domestic owner) that is disregarded as an entity separate from its owner under Treasury regulations section 301.7701-3, enter the owner's name on the ''Name line. Enter the LLC's name on the ''Business name line. Check the appropriate box for your filing status (sole proprietor, corporation, etc.), then check the box for ''Other and enter ''LLC in the space provided.

Other entities. Enter your business name as shown on required federal tax documents on the ''Name line. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the ''Business name line.

Note. You are requested to check the appropriate box for your status (individual/sole proprietor, corporation, etc.).
Exempt From Backup Withholding

If you are exempt, enter your name as described above and check the appropriate box for your status, then check the ''Exempt from backup withholding box in the line following the business name, sign and date the form.Part I. Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN. If you are a single-owner LLC that is disregarded as an entity separate from its owner (see Limited liability company (LLC) on page 2), enter your SSN (or EIN, if you have one). If the LLC is a corporation, partnership, etc., enter the entity's EIN. Note. See the chart on page 4 for further clarification of name and TIN combinations.

How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local Social Security Administration office or get this form online at www.socialsecurity.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/businesses and clicking on Employer ID Numbers under Related Topics. You can get Forms W-7 and SS-4 from the IRS by visiting www.irs.gov or by calling 1-800-TAX-FORM (1-800-829-3676).

If you are asked to complete Form W-9 but do not have a TIN, write ''Applied For in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.

Note. Writing ''Applied For means that you have already applied for a TIN or that you intend to apply for one soon. Caution: A disregarded domestic entity that has a foreign owner must use the appropriate Form W-8. What Name and Number To Give the Requester

For this type of account:

Give name and SSN of:

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 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 For this type of account:
Give name and EIN of: A valid trust, estate, or pension trust 6. Corporate or LLC electing corporate status on Form 8832 7. Association, club, religious, charitable, educational, or other tax-exempt organization 8. Partnership or multi-member LLC 9. A broker or registered nominee 10. 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 11. Sole proprietorship or single-owner LLC 12.

Legal entity 4 The corporation The organization The partnership The broker or nominee The public entity The owner 3

1. 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.

	INDEPENDENT BROKER AGREEMENT
Scanned license:	if you are unable to upload a copy, please fax a copy to 651-649-3502

Agent or Agency ("Broker"):

Social Security No. or Tax Identification No.:

Street Address:

Email Address:

Effective Date:
This Agreement is made by the above-named Broker (also "you," "your", or "yours") and Citizens Security Life Insurance Company, a Kentucky corporation (the "Company"). 1. APPOINTMENT: The Company appoints and authorizes you, as an independent contractor, to solicit the sale of and sell the Company's group insurance policies listed in the Company's Commission Schedule(s) provided to you (the "Policies") according to the terms hereof. No territory is assigned exclusively to you. 2. RESPONSIBILITIES: a) You are authorized: (1) to collect initial premiums for the Policies made payable to the Company; and (2) to remit these initial premiums in full immediately to the Company or its designee without making any deductions therefrom. Premium must be only in the form of check, draft, or money order made payable to the Company. You should never accept cash or deposit an initial premium check, draft, or money order to your personal or business account b) All premiums and any other funds due the Company which come into your possession are received in a fiduciary capacity only, and you will handle such premiums and other funds in accordance with law, and you will remit such premiums and other funds immediately to the Company. c) You will: (1) promote the sale of the Policies according to the Company's underwriting guidelines which are communicated to you; (2) strive to achieve an underwriting profit on the Policies sold by you; (3) meet in a manner fully consistent with (1) and (2) of this Section 2(c) any sales quotas set for you by the Company. d) You will conduct your business affairs in a highly responsible and reputable manner designed to further the interests of the Company. e) While this Agreement is in effect, you will maintain errors and omissions insurance with limits of liability and deductible amounts, and issued by a carrier, acceptable to the Company. f) The Company is not liable to you or to any other person for any expenses you incur or for damages of any kind or nature caused by you, and you will defend and protect the Company and its affiliates and hold the Company and its affiliates harmless against the claim or demand of any person for damages by reason of any willful or unauthorized or negligent act or omission of yours. g) You shall not be liable to the Company nor any other person for any expenses the Company incurs or for damages of any kind or nature caused by an employee of the Company. The Company will indemnify and defend you against the claim or demand of any person for damages by reason of any willful or unauthorized or negligent act or omission of the Company or an employee of the Company. 3. LIMITS OF AUTHORITY: a) If you desire to place advertising which names the Company, you must first receive the written approval of the Company or its designee. b) You have no authority to modify or waive any term of any insurance application, Policy, or underwriting guideline or rate pertaining to a Policy. c) You may not bind the Company on any type of contract other than the Policies, or do any other thing on behalf of the Company not expressly authorized herein. 4. PROCEDURE: a) The Company or its designee will bill policyholders directly and will collect from policyholders all premiums subsequent to the initial premium paid in connection with any issued Policy, and all such premiums will be payable by the policyholder directly to the Company or its designee. You will strive to ensure that all premium payments made by policyholders, subsequent to the initial premium payment, are paid directly to the Company or its designee. You will service all Policies sold by or referred to you in a manner calculated to maintain friendly relations among policyholders, you, and the Company. b) The acceptance, continuance, cancellation, and rejection of insurance coverages and payment of all claims rest exclusively with the Company or its designee. Should the Company or its designee for any reason refund any premiums on a Policy written by or referred to you, you will be liable for the repayment of any commissions received on such refunded premiums. 5. COMPENSATION: a) As compensation for the sales and services you render hereunder where you are designated as the agent of record, you will be paid commissions for the Policies you sell and service, and which are paid for, according to the terms of the Company's Commission Schedules. b) You agree to comply with all regulatory requirements related to the disclosure of broker or agent compensation. c) The Company or its designee may: (1) upon 15 days' prior written notice to you, add new Policies to, or delete any Policy from, the Company's Commission Schedules; (2) without prior written notice to you, change any premiums for Policies to be sold thereafter; or (3) upon 15 days' prior written notice to you, change the commission payable on any Policy or modify the Company's Commission Schedules in any manner. d) The Company or its designee may deduct from your commissions and other compensation the amount of any of your short remittances of premiums or other indebtedness to the Company, and if current commissions and other compensation due you are not sufficient to offset the amount of such short remittances or indebtedness, you will immediately remit such difference to the Company or its designee upon demand. 6. TERMINATION: a) This Agreement may be terminated by the Company, its designee or you, without assigning cause, upon 30 days' prior written notice delivered personally or sent by overnight courier or certified mail with postage fully prepaid to the other party at the addresses shown in this Agreement, and may be terminated by the Company or its designee, for cause, at any time upon written notice to you. As used in the preceding sentence, "for cause" includes, but is not limited to, a single instance of: (1) mishandling or misappropriation of premium by you or an employee or agent of yours; (2) failure to follow the Company's underwriting guidelines communicated to you; (3) your violation of any term of this Agreement; or (4) your violation of any applicable statute, regulation, or other law. b) Upon termination of this Agreement, you will remove immediately from your place of business, at your expense, all signs relating to the Company, and you will cease to hold yourself out to anyone as the Company's agent. c) Upon termination of this Agreement, you will be entitled only to commissions which are then unconditionally due and payable, less the amount of any and all obligations of yours due or to become due the Company, including, but not limited to: (1) premiums; (2) commission returns on terminated Policies; (3) the replacement cost of unreturned or damaged signs, manuals, rate books, and supplies; (4) the cost of reconstructing undelivered or incomplete flies and records necessary to service the Company's insureds or insurance business; and (5) all of the other costs of the Company or its designee resulting from your failure to comply with the terms of this Agreement. Any amount you are entitled to hereunder upon termination of this Agreement will be paid to you as soon as practicable after such termination. d) Upon written notice of the termination of this Agreement, the Company or its designee will be entitled to immediate possession of, and, upon the Company's or its designee's request, you will deliver to the Company all files and records necessary to service the Policies, and the Company or its designee will, after such delivery, be responsible for the servicing of such insureds and insurance business. Upon termination of this Agreement, the Company or its designee will be entitled to immediate possession of, and within 24 hours after such termination, you will deliver to the Company or its designee: (1) any and all files and records necessary to service the Company's insureds or insurance business which were not previously returned to the Company or its designee; (2) all material bearing the name or insignia of the Company, including all signs, manuals, rate books, forms, sales aids, stationery, envelopes, applications, and Policies; and (3) any and all other material or property furnished by or owned by the Company or necessary to service the Company's insureds or insurance business. 7. GENERAL PROVISIONS: a) You are an independent contractor, not an employee. You agree that because you are engaged in your own independent business, you will not participate in any pension or retirement (including, but not limited to, annuity) benefits or be eligible for unemployment compensation benefits or workers compensation benefits from or through the Company. You will: (1) Exercise your own judgment with respect to, and be responsible for, controlling the manner of your performance hereunder; (2) Be responsible for scheduling and controlling the number of hours to be worked; (3) Be responsible for providing your place of business and business equipment, at your expense; (4) Be compensated for services performed hereunder only in direct relation to sales produced and in accordance with the current applicable company commission schedules; (5) Secure an employer identification number, if necessary, and maintain detailed records of income and expense with respect to the services performed hereunder adequate to prepare federal and state income tax returns: and (6) Timely file all tax returns and reports required of self-employed independent contractors by federal, state, and local government authorities. You acknowledge that neither the Company nor its designee will withhold any taxes from your earnings, or pay any taxes on your behalf, and that you are solely responsible for the payment of all taxes directly or indirectly related to the payment of compensation for your services hereunder. You will secure and maintain in force your own Workers' Compensation coverage (or similar coverage, if not qualified therefore) and public liability insurance coverage with limits of liability acceptable to the Company, and you will provide certificates of such coverages to the Company upon request. Such certificates will provide, among other things, that no such coverage may be modified or terminated without at least 10 days' prior written notice to the Company. c) The Company or its designee may during ordinary business hours inspect, audit, and copy any or all of your files, books, accounts, and records relating to the Company’s insureds or insurance business. d) Except as provided in Sections 5(c) and 6(a) of this Agreement, this Agreement may be amended only in a written instrument signed by the parties. e) This Agreement shall be binding upon the parties, their successors, and permitted assigns. Neither party shall assign its rights, duties, or obligations hereunder without obtaining the consent of the other party, except that the Company may assign its rights, duties, and obligations hereunder to another insurance company designated by the Company. By entering into this Agreement, you agree to such assignment by the Company to an insurance company designated by the Company without any further action or obligation on the part of the Company. f) If any term of this Agreement violates any applicable statute, regulation, or other law in your territory, that term is hereby automatically amended to conform to the minimum relevant requirements, if any, provided under such statute, regulation, or other law. g) Failure of the Company to insist upon compliance with any of the terms of this Agreement or with any of the instructions or the underwriting guidelines communicated to you will not be construed as a waiver thereof unless the Company or its designee in each instance so provides in writing, but all of the same will continue in full force and effect. You understand and agree that the Company and its designee reserves the right to be inconsistent in administering broker agreements from one person to another, and you hereby waive any and all claims based upon or arising out of any such inconsistency. h) You acknowledge having read and understood this Agreement in its entirety and having had an opportunity to consult with legal or other counsel regarding this Agreement prior to signing the same. i) Any right of the Company regarding any of your duties hereunder may be enforced in any appropriate manner including, but not limited to, injunctive or other equitable relief when the circumstances justify the same. 8. SIGNATURES: IN WITNESS WHEREOF, you and, by their authorized representatives, the Company have executed this Agreement effective as of the day and year first written above.

Citizens Security offers an Electronic Fund Transfer (EFT) option to agents. We believe the opportunity to provide the EFT option for commission payments will be a benefit to our agents. The EFT option provides us the opportunity to deposit commission payments directly into your bank account, avoiding the delays in the mail system.

With the EFT option, deposits will be made direct. Processing is completed in 48 hours, and the commission statements will continue to be mailed.

We have enclosed an EFT form. If you would like to take advantage of this option, please complete the following form and return it to our office, along with a voided check.

If you have any questions, or if we may be of any further service, please do not hesitate to contact us.

Sincerely,

Jim Knox
Sr. Vice President, Group Benefits

New
Change
No Thanks

ELECTRONIC FUNDS TRANSFER AUTHORIZATION

I hereby request and authorize to initiate credit entries to my checking/ savings account indicated below at the depository financial

institution named below, and to credit the same to such account. I acknowledge that the origination of these transactions to my account must comply with the

provisions of U.S. law.

I agree that this authorization, unless terminated sooner by the Company, is to remain in effect until receipt by the company of written notice from me of its

revocation in such a manner as to afford Company and depository a reasonable opportunity to act on it.


Signature of Depositor	Date 02/06/2012	Signature of Depositor (if joint account)	Date 02/06/2012

Name of Depositor(s) as it appears on bank records

Name of Bank

Address of Bank or Branch Office Where Account is Maintained
ATTACH SAMPLE / COPY CHECK MARKED "VOID" Check if you are unable to upload a copy, please fax a copy to 651-649-3502

ADDENDUM

Citizens Security Life Insurance Company
Privacy Policy

The Financial Services Modernization Act of 1999 (Graham-Leach-Bliley) has brought about a number of changes to the financial service industry. One of the most significant changes was how we handle our customers' private, nonpublic information.

Private, nonpublic information will mean any financial or health information furnished to you, your agents, or your employees by any of our customers. Citizens Security Life does not disclose nor do we reserve the right to disclose personal financial or health information about our current or former customers. In order for you to maintain your agency agreement, you must understand:

1. Neither you, your agents, nor your employees can disclose or use any of our customer information for any purpose other than to carry out the duties and the functions of your agency agreement.

2. You cannot disclose any of our customers information to any other person or entity without written consent.

3. You must establish appropriate safeguards to protect against the inadvertent disclosure of our customers information to any other person or entity.

4. In the event of any improper or unauthorized disclosure of our customers information while in your, your agents, or employees custody or control, you must immediately notify us so that we can take appropriate remedial action.

Sr. Vice President, Group Benefits


Email Address

Year agency started		Years in employee benefits business:

Geographic area served by your agency:

Number of sales or account reps:		Number of Administrative/Support staff:
Client size (# of lives) Individual	l2- 50 51-100 101-500 501 +