ga level 6 john hopkins healthcare llc contracting checklist · 2015-09-04 · gsnational...

GSNATIONAL INSURANCE. 300 BILMAR DRIVE. SUITE 200. PITTSBURGH, PA 15205 WWW.GSNATIONAL.COM

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GA Level 6

John Hopkins HealthCare LLC Contracting Checklist:

Please complete and return ALL of the attached contracting for John Hopkins HealthCare LLC:

___ Contracting Packet Completed:

Complete and sign pages 2, 3, 6, 7, AND 9 and return contracting packet including:

___ Attachment A – Code of Conduct Acknowledgment Form

___ Electronic Payment (ACH) Authorization plus a copy voided check for direct deposit (EFT Only)

___ W-9 Form

___ Assignment of Commissions form - complete if you will be assigning your commissions to your agency

___ Copy of current E&O policy/coverage

___ Copy of valid MD State license

___ Copy of 2016 AHIP

***An agent certification test is required. Arrangements will be made through Insurance Company for the test after

initial review of contracting.

Please email completed paperwork to:

[email protected]

or

Fax to:

412 921-6950

If you have any questions, please call 412 921-6900 and ask for contracting department.

Thank you.

http://www.gsnational.com/

mailto:[email protected]

GSNATIONAL INSURANCE. 300 BILMAR DRIVE. SUITE 200. PITTSBURGH, PA 15205 WWW.GSNATIONAL.COM

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BROKER INFORMATION SHEET

1. Has your insurance license ever been suspended or revoked by any insurance regulatory body? □ Yes □ No

2. Have you ever been named as a party to a lawsuit involving a policy of insurance you sold, or has any company you sold for been named in a lawsuit as a result of a policy you sold?

□ Yes □ No

3. By signing below, you acknowledge that you may not market, solicit or sell Medicare Advantage plan(s) until you have been appointed to do so and until you have been provided an Agent

Writing Number (AWN for such appointment. Further, you attest that you will only engage prospective Beneficiaries in accordance with annual enrollment guidelines established by CMS and only

for enrollment periods and products for which you have been certified and provided an AWN.

I hereby certify that I am acting on my own behalf and that the foregoing statements are true and correct to the best of my knowledge and belief.

SECTION 1: FORM PURPOSE

□ Initial Appointment □ John Hopkins HealthCare LLC

SECTION 2: BROKER INFORMATION

First Name M.I. Last Name Social Security #

Date of Birth (MM/DD/YYYY) National Producer # (NPN) Business Phone Number Ext.

Email Address Fax Number Mobile Number

Mailing Address City State ZIP Code

Physical Address (if different) City State ZIP Code

Doing Business as:

□ Individual □ Business Entity

Business Name Business Tax ID

□ Agent Assigns Commissions To Agency

□ Agent Paid Direct

Business Address City/State Zip Code

SECTION 3: FMO/AGENCY AFFILIATION

FMO: General Agent / Up line (if applicable):

□ GS National ________________________

SECTION 4: E & O POLICY INFORMATION - Please include a copy of your declaration page or certification with application.

Policy Amount Policy # Policy Carrier Effective Date Expiration Date

SECTION 5: LICENSING QUESTIONS

Broker Signature: Date (MM/DD/YYYY)

X

http://www.gsnational.com/

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MEDICARE PRODUCTS GENERAL AGENT AGREEMENT

The Agreement is made as of ______________, 2015 by and between GS National Insurance

(“Agency”) with offices at 300 Bilmar Drive. Suite 200. Pittsburgh, PA 15205 and

______________________________________ at _____________________________.(“Agent”).

WHEREAS, “Agency” is providing managed services for various Medicare Advantage

products (the "Products") of John Hopkins HealthCare LLC (“Sponsoring Company”) to

“Agent”;

WHEREAS, “Agent” will gain appointment to market and solicit Medicare advantage

products on behalf of “Sponsoring Company” and is licensed under the insurance laws of the

soliciting state as required to perform under this Agreement.

NOW, THEREFORE, in consideration of the covenants and mutual promises set forth

herein, and intending to be legally bound hereby, both parties agree as follows:

a. Duties of Agent. The Agency hereby appoints Agent to solicit applications for John Hopkins HealthCare LLC (hereinafter, the “Sponsoring Company”) and to service the insurance agreements procured by the Agent.

b. Relationship of the Parties.

a. The parties expressly agree that Agent will be an independent contractor of the Agency and that nothing in the Agreement will be construed to create an employer/employee relationship between the parties and that Agent shall not hold himself/herself out in any capacity other than as an independent agent of Agency.

b. Agent specifically agrees that he/she will be responsible for all payments required to be made under the Federal Insurance contributions Act (FICA), the Social Security Act, the Federal or State Unemployment Tax Act, Income Tax Withholding, and/or Workmen’s Compensation.

c. Agent shall be free to exercise his/her own independent judgment as to the time, place and manner in which he/she performs the services provided for by this Agreement except that Agent, in the performance of such duties, shall not breach and local, state or federal regulation or conduct business which in anyway would be unethical as set forth by the insurance industry or impair the good will or reputation of the Agency.

d. Agent shall be responsible for and pay any and all expenses incurred in conducting business under the terms of this Agreement, including the procurement and payment of all licenses and errors & omissions insurance. Agent is not eligible to participate in any fringe benefit programs sponsored by the Agency for employees.

GATEWAY STRATEGIES, LLC. AGENT CONTRACT PAGE 4

c. Limitations on Agent’s Authority.

a. Represent himself/herself as an employee, partner, joint venture or associate of the Agency or as an agent of the Agency or of the “Sponsoring Company” for any purpose other than that specified herein.

b. Modify or waive, in any respect, any of the terms, provisions, limitations, conditions or premium rates regarding any applications, policies, receipts, announcements, or promotional or instructional materials.

c. Utilize any Advertisement regarding the Sponsoring Company or their products without obtaining prior approval. For the purpose of this Agreement, the term “Advertisement” means any printed or published or audio visual material or sales talks utilized in direct mail, newspaper, radio or televisions scripts, billboards, websites, or similar displays where such Advertisement utilizes the Sponsoring Companies names or logos or refers to any of their products.

d. Retain any portion of a collected premium as commission; or

e. Bind the Sponsoring Company to any coverage or risk. No coverage will be effective with respect to any application until approved. The Agency and the Sponsoring Company reserve the right, based on their sole discretion and without liability to the Agent, to approve or disapprove any application.

d. Compensation.

a. Agent’s sole compensation for the services provided in this Agreement shall be in the form of First Year Commissions, Renewal Commissions, and Service fees as described in the Commission Agreement attached. The Agency may amend the Commission Schedule at its sole discretion, as it pertains to Service Fees.

e. Termination of Insurance or Denial of Application.

a. The Agent shall not be entitled to any commissions upon any application declined or rejected by the Agency or the Sponsoring Company; or upon any unearned portion of any policy canceled by or at the request of the insured.

f. Termination of Agreement

a. Either party may terminate this Agreement, with our without cause, by providing two weeks’ notice to the other party by certified mail.

b. This Agreement shall terminate immediately upon any of the following:

i. Cancellation or revocation of the Agent’s license to sell or solicit insurance by the state they conduct business in;

ii. The Agent’s death or total disability, whether mentally or physically caused;

iii. The Agent’s failure to pay over on demand any money due to or belonging to the Agency;

iv. A determination by the Agency that the Agent has committed fraud, misappropriated or withheld funds, failed to property remit funds or deliver policies, or violated any criminal or insurance laws, or interfered with the Agency’s business, or,

v. Violation or breach of any provision of this Agreement by the Agent.

g. Effect of Termination.

a. Upon termination of this Agreement for any reason, Agent shall return or destroy all PHI received from, or created, received, maintained, or transmitted by Agent on behalf of, Sponsoring Company that Agent still maintains in any form.

h. Release.

a. In the event the “Agent” desires to transfer from “Agency” to another brokerage agency that sells Sponsoring Company products, a request for release must be delivered by certified mail to the “Agency” address herein. The “Agency” will have sole discretion to the approval of such release.


i. Indemnification.

i. The Agent agrees to defend, indemnify and hold harmless the Agency against any and all claims (including, but not limited to, reasonable attorney fees incident thereto) which arise out of Agent’s actions pursuant to this Agreement, including claims arising out of the Agency’s own negligence, unless a judicial determination is made that the claim results solely from the negligence of the Agency. The Agency, reserves the right, at its sole option, to defend any claim and expend such sums as may be necessary, including attorney’s fees, and Agent shall immediately reimburse Agency for any such sums.

j. Liability Insurance.

a. Agent agrees that he/she shall carry Errors and Omissions liability insurance covering the Agent and the Agency in an amount not less than $1,000,000 per occurrence while this Agreement is in affect. Agent shall provide written proof of such insurance to Agency upon request.

k. Severability.

a. Each provision and sub-provision of the Agreement shall be interpreted in such manner as to be effective and valid under applicable law, but if any provision of the Agreement shall be adjudged to be invalid under applicable law, the remainder of the Agreement shall continue in full force and effect. Should a court of competent jurisdiction declare any of the provisions of the Agreement unenforceable, the parties agree that the court may revise or reconstruct such unenforceable provisions to better effectuate the intent of the parties.

l. Protected Health Information.

a. Agent is contractually obligated to the Covered Entities(beneficiaries) to protect and secure any PHI that Agent receives from or on behalf of the Covered Entities in accordance with HIPAA, as defined herein.

i. Agent intends to protect the privacy and provide for the security of PHI disclosed pursuant to this Agreement in compliance with the Health Insurance Portability and Accountability Act of 1996, Subtitle D of the Health Information Technology for Economic and Clinical Health Act of 2009 ("HITECH"), and regulations and other guidance promulgated under both laws by the U.S. Department of Health and Human Services (collectively, "HIPAA"), as well as other applicable federal and state laws.

m. Disclosure for Administration/Legal Responsibilities. a. Disclose PHI, but only to the minimum extent necessary, for the proper

management and administration of Agent or to carry out the legal responsibilities of Agent, provided that:

i. The disclosures are Required by Law; or ii. Agent obtains reasonable assurances from the person, or other entity,

including Agent, to whom the PHI is disclosed that it shall remain confidential and shall be used or further disclosed only as Required by Law or for the purpose for which it was disclosed to the agent, person, or other entity (which purpose must be consistent with the limitations imposed upon Agent pursuant to this Agreement), and that the agent, person, or other entity, agrees to promptly notify Agency of any instances of which it is aware in which the confidentiality of the information has been breached.


n. Reporting of Improper Use or Disclosure, Breach of Unsecured PHI, or Security Incident.

a. Agent shall report within five (5) business days to Agency any use, access, acquisition or disclosure of PHI not provided for by this Agreement of which it becomes aware and (2) any Security Incident of which it becomes aware, including, with respect to (1) and (2), Breaches of PHI as required by 45 C.F.R. § 164.410. With respect to (1), Agent shall report the use or disclosure even if it determines that the use or disclosure does not pose a significant risk of financial, reputational or other harm to the individual who is the subject of the PHI. All such reports shall be made to Agency without unreasonable delay after becoming aware of such issue(s), and in any event not to exceed five (5) business days following a Discovery of a Breach. In the case of a Breach, Agent shall provide Agency with the information required pursuant to 45 C.F.R. § 164.410(c) and shall reimburse Agency for all costs, expenses and damages (including reasonable attorney's fees) associated with any notification process required under HITECH or state breach notification laws.

o. Notice.

a. Any Notice required to be given under this Agreement shall be sent by certified U.S. mail, return receipt requested, addressed as follows:

For the Agency:

GS National Insurance

300 Bilmar Drive. Suite 200

Pittsburgh, PA 15205

p. Non-Waiver. a. Forbearance or neglect on the part of the Agency to insist upon compliance by

the Agent with the terms and provision of the Agreement and rules and regulations of the Agency shall not be construed as or constitute a waiver thereof.

GS National Insurance Agent: By: _ By: Name: Brian Breisinger Name:


COMPENSATION AGREEMENT – LEVEL 6 (GA)

This agreement is for the payment of commissions for John Hopkins HealthCare LLC,

hereinafter referred to as the "Sponsoring Company". The agreement is between GS National

Insurance, hereinafter referred to as "GSNI" and_________________________________

hereinafter referred to as “agency".

1. By accepting commission payments from "GSNI", "Agency" agrees to all of the "General

Conditions" of this contract. If "Agency" is a corporation, the owners of the corporation agree to be

personally, jointly and severally liable to this agreement.

2. “Agency” agrees to allow "GSNI" and “Sponsoring Company” to conduct monitoring

activities including Ride Alongs and Secret Shopping activities.

3. General Agency Agreements:

3.(a) “ Agency ” agrees to monitor its downline agents marketing activities and

follow an agent oversight plan mutually agreed upon by "GSNI", “Agency” and

"Sponsoring Company". “Agency” shall conduct marketing oversight and ride-alongs

with at least ten percent (10%) of the employed writing agents and shall promptly furnish

to “GSNI” any and all documentation of such ride-alongs and outcomes by the end of the

Annual Election Period (AEP).

3.(b) “Agency” agrees to provide administrative services. This includes, but is

not limited to: maintaining adequate records and upon reasonable notice shall provide

“GSNI” access to and the right to audit all information and records related to the

administrative services rendered by “Agency”.

4. "GSNI" shall pay commissions to "Agency" according to the terms of this agreement,

however, nothing in this agreement shall be construed to violate the Marketing Guidelines of the

Center for Medicare and Medicaid Services nor shall this agreement violate the terms and conditions

of the Field Marketing Organization agreement between "GSNI" and the "Sponsoring Company".

If there is any conflict between this agreement and the aforementioned, this agreement shall be

amended to adhere to CMS regulations and to the "Field Marketing Organization" agreement terms

and conditions.

5. "GSNI" shall not be responsible to pay any commissions to "Agency" for any

commissions where "GSNI" does not receive compensation from the "Sponsoring Company".

6. "Initial" First Year Commissions and "Replacement" First year commissions are

determined by the "Sponsoring Company" in accordance with CMS Marketing Guidelines.

"GSNI" will pay the "Initial" first year commission or "Replacement" first year commission in

accordance with the "Sponsoring Company" payment. "GSNI" is not responsible for any dispute

involving determining whether a first year commission is "Initial" or "Replacement".

7. "GSNI" will pay Commissions within seven (7) days of receipt of payment from

“Sponsoring Company”.


8. The "Sponsoring Company" may charge back commissions to "GSNI" for a variety of

reasons including but not limited to: Rapid Disenrollment of the member, Early Termination of the

member, Corrections of Commissions paid to "GSNI" in error, etc. In cases where "Sponsoring

Company" charges back commissions to "GSNI", "GSNI" will charge back all or a portion of

commissions previously paid to "Agency". "Agency" agrees to promptly repay any debit balances

which may accrue due to charge backs to the "Agency" account by "GSNI". If "Agency" does not

promptly repay any "Debit" balances within sixty (30) days, "Agency" agrees to forfeit any future

commission payments until “Debit” balance is cleared.

9. Agent acknowledges and agrees to cooperate with “GNSI” and “Sponsoring Company”

on the submission of all licensure and background information in a timely and accurate manner.

10. Commissions are 100% vested with the "Agency" immediately subject to the following terms:

a. "Agency" remains "in good standing" with "Sponsoring Company"

according to CMS Marketing Guidelines and "Sponsoring Company"

continues to pay commission to "GSNI" for "Agency" business. “Good

Standing” means appointed to sell.

b. "Agency" is not terminated for cause. Termination for cause includes violating

the "Sponsoring Company" Code of Conduct, violating CMS Guidelines,

violating state insurance law, violating the "Agent" contract with the "Sponsoring

Company", bankruptcy or failure to maintain a valid insurance license.

c. If “Agency” moves from “GSNI” hierarchy:

• Vested commissions will continue according to “Sponsoring

Company” commission structure; as long as, Section 10 (a) & (b)

conditions are met.

11. Definitions for Commission levels. Writing Agent levels are defined as Agent 4.

12. Agency levels have the following requirements on the minimum number of downline

agents in the hierarchy:

GA (Level 6) - Minimum of 5 Agents in Good Standing with "Sponsoring Company."


For ALL Plans – Initial (From Original Medicare or New to Medicare, determined by CMS).

First payment will be made at the Replacement level until Sponsoring Company is notified by

CMS to release the initial compensation and Sponsoring Company pays this to GS National

For ALL Plans – Initial (From Original Medicare or New to Medicare, determined by CMS).

First payment will be made at the Replacement level until Sponsoring Company is notified by

CMS to release the initial compensation and Sponsoring Company pays this to GS National

M a r y l a n d

Level Title 2016 MA/MAPD

Year 1

Renewal

Years 2+

6 GA $474.00 $240.00

4 Agent 4 $429.00 $215.00

For Replacement Commissions excluding replacement of Sponsoring Company Individual

Medicare Advantage (as defined by CMS)

M a r y l a n d

Level Title 2016 MA/MAPD

Renewal Year 1

Renewal

Years 2+

6 GA $260.00 $240.00

4 Agent 4 $215.00 $215.00

GS National Insurance Agent:

By: ____________________________ By:__________________________

Name: Brian Breisinger Name:_______________________


ATTACHMENT A

CODE OF CONDUCT ACKNOWLEDGMENT FORM

In the performance of my duties as a CBA or Subagent for John Hopkins HealthCare LLC, I hereby acknowledge the following:

2. I shall abide by all applicable laws, regulations, and rules, including, but not limited

to, those of the Centers for Medicare & Medicaid Services (CMS) and the laws of the state(s)

for which I maintain a valid state insurance license. I shall cooperate and comply with any

and all policies, procedures, instructions and directives, oral and written, John Hopkins

HealthCare LLC may require. I shall be familiar with and maintain good working knowledge,

through self/independent means, of the policies and procedures of the Medicare Marketing

Guidelines and Medicare Operational Letters and Manuals.

3. I understand that in order to market, solicit or sell Medicare Advantage plans, I must

annually complete training and pass a certification test as set forth by John Hopkins

HealthCare LLC and required by CMS.

4. I understand that I may not market, solicit or sell Medicare Advantage plans until I

have been appointed to do so and until I have been provided an Agent Writing Number

(AWN) as confirmation of such appointment. I have been informed that I may engage

prospective Beneficiaries only in accordance with annual enrollment guidelines established

by CMS and only for enrollment periods and products for which I have been certified and

provided an AWN.

5. I will use only the AWN assigned to me on enrollment applications. I will not use

the AWN of another broker on any enrollment applications solicited by me, nor will I place

my AWN or signature on an application that I did not solicit.

6. I shall maintain a valid State(s) Accident and Health Insurance license (as applicable

in the State(s) in which I am soliciting insurance product(s) and Errors & Omissions

Insurance (E & O), and shall provide proof of in-force E & O coverage to John Hopkins

HealthCare LLC. I shall notify my up line immediately upon limitation, suspension,

cancellation or expiration of such license(s). I shall also promptly notify my up line of any

disciplinary proceedings related to my license(s) or any investigatory proceedings instituted

by CMS, and/or the insurance regulation departments of any other state or commonwealth.

7. I shall comply with all the terms of the Health Insurance Portability and

Accountability Act (HIPAA) privacy and confidentiality laws. I shall notify my up line

immediately upon failure to safeguard Medicare beneficiary protected health information that

is in my possession.

8. I have the duty to notify my up line within five (5) days of any and all actions

regarding my non- compliance with any of the policies and procedures of John Hopkins

HealthCare LLC, and/or non-compliance with Medicare Marketing Guidelines, and/or non-

compliance with the applicable state laws.


9. I will not ask a Beneficiary to sign an incomplete enrollment application. I shall follow the

enrollment process and provide all enrollment applications to John Hopkins HealthCare LLC

within 48 hours following receipt of the acknowledged application from the Beneficiary. Failure

to comply with the 48 hour submission requirement and the required enrollment process may

result in non-payment of commissions due to non- compliance.

10. I shall, at all times, convey truthful benefit information, or otherwise that is known to me at the

time as truthful information and not make confusing, misleading or false statements to

prospective enrollees in my role as advisor and educator. I will do what is best for the beneficiary

without regard to compensation and ensure that the Beneficiary's needs come first.

11. I am aware that marketing activities in connection with the sales of products to consumers are

strictly regulated by both state and federal regulations and I agree to comply with these

regulations. I shall not engage in any prohibited sales practices including, but not limited to:

a. Making unsolicited home visits; b. Soliciting Beneficiaries door-to-door prior to receiving an invitation from the

Beneficiary; c. Sending unsolicited emails to a Beneficiary unless the Beneficiary agrees to receive

emails and has provided his/her address to the organization; d. Misrepresenting, intimidating, or using high-pressure sales tactics. If Beneficiary

says he or she is not interested, the conversation must end; e. Offering Beneficiaries a cash payment as an inducement to enroll in a Medicare

Advantage Part C or Medicare Advantage Prescription Drug (Part D) plan; f. Stating that I work for or am contracted with the Social Security Administration

(SSA) or the Centers for Medicare & Medicaid Services (CMS); g. Misrepresenting a product being marketed as an approved Medicare Advantage

Prescription (Part D) plan; h. Using an unapproved presentation or material; i. Marketing or enrolling other lines of business. Additional products that were not

identified, agreed upon, and documented in the scope of appointment cannot be

discussed unless the Beneficiary requests this information. A separate appointment is

required to discuss additional products and a 48 hour "cool off" period must be observed

before a second appointment can be scheduled; j. Conducting outbound telephone enrollment, which also includes transferring

outbound calls to inbound lines for telephone enrollment; k. Engaging in forgery, including manually assisting Beneficiary with the signing of the

enrollment application; l. Enrolling Beneficiary(s) at educational events, or in health care settings (waiting

rooms, exam rooms, hospital patient rooms, dialysis center, etc.); and p. Scheduling

unauthorized group presentations. I must obtain approval from John Hopkins HealthCare

LLC prior to organizing or advertising a group presentation (30) days in advance.


A copy of this form has been provided to me as well as placed in my individual file at the Field

Marketing Organization. By signing this Acknowledgment Form, I understand the contents and I will

abide by the requirements as set forth above. I understand that any breach of the above could result in

correction action up to and including appointment termination.

ACKNOWLEDGED AND AGREED BY:

-------------------------------------------------------- --------------------------------------- Signature Date

-------------------------------------------------------- Print Name & Title

------------------------------------------------------- Organization

GS National Insurance. 300 Bilmar Drive. Suite 200. Pittsburgh, PA 15205. Phone: (412) 921-6900 Fax: (412) 921-6950

Electronic Payment (ACH) Authorization Agreement

I hereby authorize Gateway Strategies to deposit any amounts owed me by initiating credit

entries to the bank account listed below in the amounts specified. Also, I authorize Gateway

Strategies the right to correct any Electronic Funds Transfer resulting from an erroneous

payment by debiting my account for an amount not to exceed the original amount of the

erroneous credit. This authorization is to remain in force until Gateway Strategies receives

written notice from me of its termination in such time and in such manner as to afford Gateway

Strategies a reasonable opportunity to act on it.

******************************VENDOR INFORMATION****************************

Name (please print):_________________________________________________

Social Security Number: _____ _____ _____- _____ _____ - _____ _____ _____ _____

OR

Tax ID Number: _____ _____ - _____ _____ _____ _____ _____ _____ _____

*****************************DEPOSIT INFORMATION*****************************

Check One: ____ Checking _____ Savings

Requested Start Date for ACH: ________________________________

Check One: _____ New ____ Change _____Stop

Bank Routing # _____ _____ _____ _____ _____ _____ _____ _____ _____

Bank Account # ______ _____ _____ _____ _____ _____ _____ _____ _____ _____

***YOU MUST ATTACH A COPY OF A VOIDED CHECK***

Signature___________________________ Date_________________

Assignment of Commissions

To __________________________________________ Tax ID ___________________________

(Legal entity that Commissions are being assigned to, hereinafter the “Assignee”)

Assignee’s Address _____________________________________________________________

City _______________________________________ State _______ Zip Code ______________

For valuable consideration, the undersigned, herein called the Assignor, hereby assigns to the Assignee

all of the Assignor’s right, title, interest, claim or demand in and to any and all compensation now due

and payable, or which may become due and payable, under existing contracts and agreements

heretofore entered into by and between Gateway Strategies (the “Company”) and Assignor.

Assignor hereby authorizes and empowers the Company to pay Assignee all compensation (including but

not limited to over-riding commissions) now due or which may become due under the Agreement until

such time as Assignor terminates this assignment by written notice to the Company. Assignor

acknowledges and agrees that such payment of compensation to Assignee shall constitute payment of

such compensation to the Assignor as if paid directly to the Assignor and the Company shall be fully

released from any and all responsibility to the Assignor for such payments. Assignor hereby

acknowledges and agrees that assignment of compensation payable under the agreement does not

release or otherwise relieve Assignor of any obligation or responsibility under the Agreement including,

but not limited to, the obligation to pay commissions to any applicable “downline” sales hierarchy

and/or the obligation to reimburse the Company for compensation paid on premiums subsequently

refunded.

Assignor hereby covenants and agrees that the Assignor is the absolute and sole owner of said

compensation, free from assignment or encumbrance of any kind or character whatsoever, and has full

right and lawful authority to so assign same. The Assignor shall at all times defend, indemnify and hold

harmless the Company and its officers, agents, and employees from and against any and all suits,

actions, losses, damages, claims, expenses (including but not limited to the Company’s legal expenses)

and liability of any character, type or description arising out of the execution or performance of this

agreement.

Assignor Signature _________________________ Date _________________________

Assignor Name ____________________________ (print name)

Assignee Signature _____________________________ Dated ________________________

The Company acknowledges receipt of, and consents to the foregoing assignment, but assumes

no responsibility for the validity or sufficiency hereof. This assignment is effective on the date

signed by the authorized representative of the Company.

By _____________________________________ (signature) Dated___________________

Authorized Company Representative _______________________ Title ____________________

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ga level 6 john hopkins healthcare llc contracting checklist · 2015-09-04 · gsnational...

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