For Trustpoint and BAI Policies Step 1 of 12 8% Choose your name from this drop down box.*Your NameAnderson, MichelleBiggio, AlanBradley, BrandiCombs, KamiCox, ZaneCuddy, EricDavis, LindaDoino, LaurenDoss, ToriDugger, AdamHelbling, LeahHelbling, RIchardKeene, DonnaPowers, EdNot ListedYour Name* Your Email* For what division is this account data?* Trustpoint Benefits Beneficial Associates Inc What Type of data are we adding?* New Business Renewal Business Account/Policy Changes Account/Policy Cancelation For how many policies are you adding data?*Please enter a number from 1 to 10.For example if there are two (2) group health, one (1) dental and one (1) vision, then enter four(4) policies.New Business Account InformationEnter Legal Name of Account* Enter DBA Name (blank if N/A) Contact Name* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Name of Producer/Account Executive* Enter Name of Account Manager/Representative* Enter Standard Industry Code for this Account (SIC)* Enter Number of Eligible Employees* Is this an existing account?*If we already have an account set up for Trustpoint P&C, Trustpoint Benefits or Beneficial Associaties Inc then select YES. Yes No Renewal / Change / Cancellation Account InformationEnter Name of Account* Has the number of eligible employees changed?* Yes No Enter Updated Number of Eligible Employees Information for 1st PolicyIs this a rewrite?* Yes No If this is a new company or policy replacing an existing policy choose YES.Enter the expiring policy number.* Choose the line of business for this policy.*Line of BusinessAccidentCancerCritical IllnessGroup LifeGroup DentalGroup Long Term CareGroup LTDGroup Medical HealthGroup STDGroup VisionHospital IndemnityIndividual DisabilityIndividual DentalIndividual DentalIndividual LifeIndividual Long Term CareIndividual MedicalIndividual VisionMASAMedicare SupplementMiscellaneous BenefitsUniversal LifeVoluntary LTDVoluntary STDVoluntary ProductsVoluntary Term LifeWhole LifePolicy Number* Enter the Effective Date of This Policy* MM slash DD slash YYYY Enter the Expiration Date of This Policy* MM slash DD slash YYYY Enter the Cancelation Date of This Policy* MM slash DD slash YYYY Enter the Reason for Cancelation* Select the Parent:Writing Company Combination for This Policy*ABACUS Group, LLC: ABACUS Group, LLCAdvisors Financial Group, Inc.: Advisors Financial Group, Inc.Advisors Financial Group, Inc.: One AmericaAetna Group: Aetna GroupAetna Group: Aetna Health, Inc.Aetna Group: Aetna Dental, Inc.Aetna Group: Aetna Life Insurance ComapnyAFLAC: AFLACAllied Benefit Insurance: Allied Benefit InsuranceAllied Benefit Insurance: Fidelity Security Life Ins CoAmerican General Life: American General LifeAmerican Heritage: American HeritageAmerican Heritage: AllstateAmerican Heritage: Assuritiy Life Insurance CoAmFirst Insurance Company: AmFirst Insurance CompanyBanner Life: Banner LifeBASIC: BASICBenefit Solutions, Inc.: Benefit Solutions, Inc.BenefitWallet: BenefitWalletBlue Cross Blue Shield of NC: Blue Cross Blue Shield of NCBlue Cross/Blue Shield TN: Blue Cross/Blue Shield TNBoston Mutual Life: Boston Mutual LifeBrighthouse Life Insurance Co: Brighthouse Life Insurance CoCigna Group Insurance: Cigna Group InsuranceCompanion Life Insurance Company: Companion Life Insurance CompanyCrump Insurances Services: Crump Insurances ServicesCrump Insurances Services: AIG Life Insurance Co.Crump Insurances Services: PrudentialCrump Insurances Services: Lincoln National Life Insurance CompanyDelta Dental: Delta DentalDominion Dental Services USA, Inc.: Dominion Dental Services USA, Inc.EyeMed Ins: EyeMed InsFidelity Life: Fidelity LifeFirst National Brokerage Group: First National Brokerage GroupFirst National Brokerage Group: TrigonFirst National Brokerage Group: American General Life InsuranceFirst National Brokerage Group: Anthem HealthPlans of VirginiaFirst National Brokerage Group: Cotton States Life InsuranceFirst National Brokerage Group: Prudential FinancialFirst National Brokerage Group: Shenandoah Life Insurance CompanyFlexible Benefit Administrators: Flexible Benefit AdministratorsFlores & Associates, LLC: Flores & Associates, LLCFort Dearborn Life: Fort Dearborn LifeFurther: FurtherGenworth Life & Annuity Insurance Company: Genworth Life & Annuity Insurance CompanyGenworth Life & Annuity Insurance Company: Colonial GroupGenworth Life & Annuity Insurance Company: First Colony Life Insurance CompanyGenworth Life & Annuity Insurance Company: First National Brokerage GroupGuardian Life Insurance Company: Guardian Life Insurance CompanyHarleysville Life: Harleysville LifeHealth Equity: Health EquityHealthSavings: HealthSavingsHumana: HumanaiSolved (Infinisource): iSolved (Infinisource)John Hancock Life Insurance Company: John Hancock Life Insurance CompanyLincoln Financial: Lincoln FinancialLincoln Financial: Lincoln National LifeMASA Global: MASA GlobalMet Life: Met LifeMet Life: Travelers Proerty & Casualty GroupMet Life: Mag Mutual Insurance CoMet Life: Metropolitan Life Insurance CoMGIS Companies: MGIS CompaniesMutual of Omaha Insurance Company: Mutual of Omaha Insurance CompanyMutual of Omaha Insurance Company: Mutual of Ohama Insurance Co.Mutual of Omaha Insurance Company: Mony Life insurance Co of AmerOptima Health: Optima Health Ins CoPetersen International Underwriters: Petersen International UnderwritersPiedmont Community Health Plan: Piedmont Community Health PlanPrimeflex Administrative Services: Primeflex Administrative ServicesPrincipal Financial Group, Inc.: Principal Financial Group, Inc.Principal Financial Group, Inc.: Principal National Life Insurance CompanyPrincipal Financial Group, Inc.: Principal Financial GroupPrincipal Financial Group, Inc.: Principal Life Insurance Co.Protective Life Group: Protective Life GroupPrudential Brokerage: Prudential BrokerageReliance Standard Life Insurance Company: Reliance Standard Life Insurance CompanySecurity Life: Security LifeShenandoah Life Insurance Company: Shenandoah Life Insurance CompanySun Life and Health Insurance: Sun Life and Health InsuranceSun Life and Health Insurance: Assurant Employee BenefitsSun Life and Health Insurance: Fortis Benefits Insurance Co.Sun Life and Health Insurance: Sun Life Assurance CompanySymetra Life Insurance Company: Symetra Life Insurance CompanyThe Standard: The StandardTransamerica Life Insurance Company: Transamerica Life Insurance CompanyTrue North: True NorthTrue North: Assurant HealthTrue North: TransamericaUnited Concordia: United ConcordiaUnited Healthcare: United HealthcareUNUM Provident: UNUM ProvidentUS Able Life: US Able LifeVested Health (The Health Plan): Vested Health (The Health Plan)Vision Service Plan: Vision Service PlanWell Point, Inc.: Well Point, Inc.Well Point, Inc.: Anthem Health Plans of VirginiaWell Point, Inc.: Anthem Life Insurance CompanyWell Point, Inc.: Anthem Blue Cross Blue ShieldOther Not ListedSpecify Parent and Writing Company Combination for This Policy* Enter Negotiated Commission Percentage* You may need to back into this by dividing the estimated revenue by the estimated premium.Enter the Annual Estimated Premium for This Policy* Enter the Annual Estimated Revenue for This Policy*Enter the name of the Account Manager/Representative for This Policy* Enter the name of the Producer/Executive for This Policy* Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.Enter Producer Commission*Enter the name of the 2nd Producer/Executive for This Policy Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.Enter 2nd Producer CommissionEnter the name of the 3rd Producer/Executive for This Policy Enter 3rd Producer CommissionEnter the name of the Broker for This Policy Enter Broker Commission Information for 2nd PolicyIs this a rewrite?* Yes No If this is a new company or policy replacing an existing policy choose YES.Enter the expiring policy number.* Choose the line of business for this policy.*Line of BusinessAccidentCancerCritical IllnessGroup LifeGroup DentalGroup Long Term CareGroup LTDGroup Medical HealthGroup STDGroup VisionHospital IndemnityIndividual DisabilityIndividual DentalIndividual DentalIndividual LifeIndividual Long Term CareIndividual MedicalIndividual VisionMASAMedicare SupplementMiscellaneous BenefitsUniversal LifeVoluntary LTDVoluntary STDVoluntary ProductsVoluntary Term LifeWhole LifePolicy Number* Enter the Effective Date of This Policy* MM slash DD slash YYYY Enter the Expiration Date of This Policy* MM slash DD slash YYYY Enter the Cancelation Date of This Policy* MM slash DD slash YYYY Enter the Reason for Cancelation* Select the Parent:Writing Company Combination for This Policy*ABACUS Group, LLC: ABACUS Group, LLCAdvisors Financial Group, Inc.: Advisors Financial Group, Inc.Advisors Financial Group, Inc.: One AmericaAetna Group: Aetna GroupAetna Group: Aetna Health, Inc.Aetna Group: Aetna Dental, Inc.Aetna Group: Aetna Life Insurance ComapnyAFLAC: AFLACAllied Benefit Insurance: Allied Benefit InsuranceAllied Benefit Insurance: Fidelity Security Life Ins CoAmerican General Life: American General LifeAmerican Heritage: American HeritageAmerican Heritage: AllstateAmerican Heritage: Assuritiy Life Insurance CoAmFirst Insurance Company: AmFirst Insurance CompanyBanner Life: Banner LifeBASIC: BASICBenefit Solutions, Inc.: Benefit Solutions, Inc.BenefitWallet: BenefitWalletBlue Cross Blue Shield of NC: Blue Cross Blue Shield of NCBlue Cross/Blue Shield TN: Blue Cross/Blue Shield TNBoston Mutual Life: Boston Mutual LifeBrighthouse Life Insurance Co: Brighthouse Life Insurance CoCigna Group Insurance: Cigna Group InsuranceCompanion Life Insurance Company: Companion Life Insurance CompanyCrump Insurances Services: Crump Insurances ServicesCrump Insurances Services: AIG Life Insurance Co.Crump Insurances Services: PrudentialCrump Insurances Services: Lincoln National Life Insurance CompanyDelta Dental: Delta DentalDominion Dental Services USA, Inc.: Dominion Dental Services USA, Inc.EyeMed Ins: EyeMed InsFidelity Life: Fidelity LifeFirst National Brokerage Group: First National Brokerage GroupFirst National Brokerage Group: TrigonFirst National Brokerage Group: American General Life InsuranceFirst National Brokerage Group: Anthem HealthPlans of VirginiaFirst National Brokerage Group: Cotton States Life InsuranceFirst National Brokerage Group: Prudential FinancialFirst National Brokerage Group: Shenandoah Life Insurance CompanyFlexible Benefit Administrators: Flexible Benefit AdministratorsFlores & Associates, LLC: Flores & Associates, LLCFort Dearborn Life: Fort Dearborn LifeFurther: FurtherGenworth Life & Annuity Insurance Company: Genworth Life & Annuity Insurance CompanyGenworth Life & Annuity Insurance Company: Colonial GroupGenworth Life & Annuity Insurance Company: First Colony Life Insurance CompanyGenworth Life & Annuity Insurance Company: First National Brokerage GroupGuardian Life Insurance Company: Guardian Life Insurance CompanyHarleysville Life: Harleysville LifeHealth Equity: Health EquityHealthSavings: HealthSavingsHumana: HumanaiSolved (Infinisource): iSolved (Infinisource)John Hancock Life Insurance Company: John Hancock Life Insurance CompanyLincoln Financial: Lincoln FinancialLincoln Financial: Lincoln National LifeMASA Global: MASA GlobalMet Life: Met LifeMet Life: Travelers Proerty & Casualty GroupMet Life: Mag Mutual Insurance CoMet Life: Metropolitan Life Insurance CoMGIS Companies: MGIS CompaniesMutual of Omaha Insurance Company: Mutual of Omaha Insurance CompanyMutual of Omaha Insurance Company: Mutual of Ohama Insurance Co.Mutual of Omaha Insurance Company: Mony Life insurance Co of AmerOptima Health: Optima Health Ins CoPetersen International Underwriters: Petersen International UnderwritersPiedmont Community Health Plan: Piedmont Community Health PlanPrimeflex Administrative Services: Primeflex Administrative ServicesPrincipal Financial Group, Inc.: Principal Financial Group, Inc.Principal Financial Group, Inc.: Principal National Life Insurance CompanyPrincipal Financial Group, Inc.: Principal Financial GroupPrincipal Financial Group, Inc.: Principal Life Insurance Co.Protective Life Group: Protective Life GroupPrudential Brokerage: Prudential BrokerageReliance Standard Life Insurance Company: Reliance Standard Life Insurance CompanySecurity Life: Security LifeShenandoah Life Insurance Company: Shenandoah Life Insurance CompanySun Life and Health Insurance: Sun Life and Health InsuranceSun Life and Health Insurance: Assurant Employee BenefitsSun Life and Health Insurance: Fortis Benefits Insurance Co.Sun Life and Health Insurance: Sun Life Assurance CompanySymetra Life Insurance Company: Symetra Life Insurance CompanyThe Standard: The StandardTransamerica Life Insurance Company: Transamerica Life Insurance CompanyTrue North: True NorthTrue North: Assurant HealthTrue North: TransamericaUnited Concordia: United ConcordiaUnited Healthcare: United HealthcareUNUM Provident: UNUM ProvidentUS Able Life: US Able LifeVested Health (The Health Plan): Vested Health (The Health Plan)Vision Service Plan: Vision Service PlanWell Point, Inc.: Well Point, Inc.Well Point, Inc.: Anthem Health Plans of VirginiaWell Point, Inc.: Anthem Life Insurance CompanyWell Point, Inc.: Anthem Blue Cross Blue ShieldOther Not ListedSpecify Parent and Writing Company Combination for This Policy* Enter Negotiated Commission Percentage*You may need to back into this by dividing the estimated revenue by the estimated premium. Enter the Annual Estimated Premium for This Policy* Enter the Annual Estimated Revenue for This Policy*Enter the name of the Account Manager/Representative for This Policy* Enter the name of the Producer/Executive for This Policy* Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.Enter Producer Commission*Enter the name of the 2nd Producer/Executive for This Policy Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.Enter 2nd Producer CommissionEnter the name of the 3rd Producer/Executive for This Policy Enter 3rd Producer CommissionEnter the name of the Broker for This Policy Enter Broker Commission Information for 3rd PolicyIs this a rewrite?* Yes No If this is a new company or policy replacing an existing policy choose YES.Enter the expiring policy number.* Choose the line of business for this policy.*Line of BusinessAccidentCancerCritical IllnessGroup LifeGroup DentalGroup Long Term CareGroup LTDGroup Medical HealthGroup STDGroup VisionHospital IndemnityIndividual DisabilityIndividual DentalIndividual DentalIndividual LifeIndividual Long Term CareIndividual MedicalIndividual VisionMASAMedicare SupplementMiscellaneous BenefitsUniversal LifeVoluntary LTDVoluntary STDVoluntary ProductsVoluntary Term LifeWhole LifePolicy Number* Enter the Effective Date of This Policy* MM slash DD slash YYYY Enter the Expiration Date of This Policy* MM slash DD slash YYYY Enter the Cancelation Date of This Policy* MM slash DD slash YYYY Enter the Reason for Cancelation* Select the Parent:Writing Company Combination for This Policy*ABACUS Group, LLC: ABACUS Group, LLCAdvisors Financial Group, Inc.: Advisors Financial Group, Inc.Advisors Financial Group, Inc.: One AmericaAetna Group: Aetna GroupAetna Group: Aetna Health, Inc.Aetna Group: Aetna Dental, Inc.Aetna Group: Aetna Life Insurance ComapnyAFLAC: AFLACAllied Benefit Insurance: Allied Benefit InsuranceAllied Benefit Insurance: Fidelity Security Life Ins CoAmerican General Life: American General LifeAmerican Heritage: American HeritageAmerican Heritage: AllstateAmerican Heritage: Assuritiy Life Insurance CoAmFirst Insurance Company: AmFirst Insurance CompanyBanner Life: Banner LifeBASIC: BASICBenefit Solutions, Inc.: Benefit Solutions, Inc.BenefitWallet: BenefitWalletBlue Cross Blue Shield of NC: Blue Cross Blue Shield of NCBlue Cross/Blue Shield TN: Blue Cross/Blue Shield TNBoston Mutual Life: Boston Mutual LifeBrighthouse Life Insurance Co: Brighthouse Life Insurance CoCigna Group Insurance: Cigna Group InsuranceCompanion Life Insurance Company: Companion Life Insurance CompanyCrump Insurances Services: Crump Insurances ServicesCrump Insurances Services: AIG Life Insurance Co.Crump Insurances Services: PrudentialCrump Insurances Services: Lincoln National Life Insurance CompanyDelta Dental: Delta DentalDominion Dental Services USA, Inc.: Dominion Dental Services USA, Inc.EyeMed Ins: EyeMed InsFidelity Life: Fidelity LifeFirst National Brokerage Group: First National Brokerage GroupFirst National Brokerage Group: TrigonFirst National Brokerage Group: American General Life InsuranceFirst National Brokerage Group: Anthem HealthPlans of VirginiaFirst National Brokerage Group: Cotton States Life InsuranceFirst National Brokerage Group: Prudential FinancialFirst National Brokerage Group: Shenandoah Life Insurance CompanyFlexible Benefit Administrators: Flexible Benefit AdministratorsFlores & Associates, LLC: Flores & Associates, LLCFort Dearborn Life: Fort Dearborn LifeFurther: FurtherGenworth Life & Annuity Insurance Company: Genworth Life & Annuity Insurance CompanyGenworth Life & Annuity Insurance Company: Colonial GroupGenworth Life & Annuity Insurance Company: First Colony Life Insurance CompanyGenworth Life & Annuity Insurance Company: First National Brokerage GroupGuardian Life Insurance Company: Guardian Life Insurance CompanyHarleysville Life: Harleysville LifeHealth Equity: Health EquityHealthSavings: HealthSavingsHumana: HumanaiSolved (Infinisource): iSolved (Infinisource)John Hancock Life Insurance Company: John Hancock Life Insurance CompanyLincoln Financial: Lincoln FinancialLincoln Financial: Lincoln National LifeMASA Global: MASA GlobalMet Life: Met LifeMet Life: Travelers Proerty & Casualty GroupMet Life: Mag Mutual Insurance CoMet Life: Metropolitan Life Insurance CoMGIS Companies: MGIS CompaniesMutual of Omaha Insurance Company: Mutual of Omaha Insurance CompanyMutual of Omaha Insurance Company: Mutual of Ohama Insurance Co.Mutual of Omaha Insurance Company: Mony Life insurance Co of AmerOptima Health: Optima Health Ins CoPetersen International Underwriters: Petersen International UnderwritersPiedmont Community Health Plan: Piedmont Community Health PlanPrimeflex Administrative Services: Primeflex Administrative ServicesPrincipal Financial Group, Inc.: Principal Financial Group, Inc.Principal Financial Group, Inc.: Principal National Life Insurance CompanyPrincipal Financial Group, Inc.: Principal Financial GroupPrincipal Financial Group, Inc.: Principal Life Insurance Co.Protective Life Group: Protective Life GroupPrudential Brokerage: Prudential BrokerageReliance Standard Life Insurance Company: Reliance Standard Life Insurance CompanySecurity Life: Security LifeShenandoah Life Insurance Company: Shenandoah Life Insurance CompanySun Life and Health Insurance: Sun Life and Health InsuranceSun Life and Health Insurance: Assurant Employee BenefitsSun Life and Health Insurance: Fortis Benefits Insurance Co.Sun Life and Health Insurance: Sun Life Assurance CompanySymetra Life Insurance Company: Symetra Life Insurance CompanyThe Standard: The StandardTransamerica Life Insurance Company: Transamerica Life Insurance CompanyTrue North: True NorthTrue North: Assurant HealthTrue North: TransamericaUnited Concordia: United ConcordiaUnited Healthcare: United HealthcareUNUM Provident: UNUM ProvidentUS Able Life: US Able LifeVested Health (The Health Plan): Vested Health (The Health Plan)Vision Service Plan: Vision Service PlanWell Point, Inc.: Well Point, Inc.Well Point, Inc.: Anthem Health Plans of VirginiaWell Point, Inc.: Anthem Life Insurance CompanyWell Point, Inc.: Anthem Blue Cross Blue ShieldOther Not ListedSpecify Parent and Writing Company Combination for This Policy* Enter Negotiated Commission Percentage*You may need to back into this by dividing the estimated revenue by the estimated premium. Enter the Annual Estimated Premium for This Policy* Enter the Annual Estimated Revenue for This Policy*Enter the name of the Account Manager/Representative for This Policy* Enter the name of the Producer/Executive for This Policy* Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.Enter Producer Commission*Enter the name of the 2nd Producer/Executive for This Policy Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.Enter 2nd Producer CommissionEnter the name of the 3rd Producer/Executive for This Policy Enter 3rd Producer CommissionEnter the name of the Broker for This Policy Enter Broker Commission Information for 4th PolicyIs this a rewrite?* Yes No If this is a new company or policy replacing an existing policy choose YES.Enter the expiring policy number.* Choose the line of business for this policy.Line of BusinessAccidentCancerCritical IllnessGroup LifeGroup DentalGroup Long Term CareGroup LTDGroup Medical HealthGroup STDGroup VisionHospital IndemnityIndividual DisabilityIndividual DentalIndividual DentalIndividual LifeIndividual Long Term CareIndividual MedicalIndividual VisionMASAMedicare SupplementMiscellaneous BenefitsUniversal LifeVoluntary LTDVoluntary STDVoluntary ProductsVoluntary Term LifeWhole LifePolicy Number* Enter the Effective Date of This Policy* MM slash DD slash YYYY Enter the Expiration Date of This Policy* MM slash DD slash YYYY Enter the Cancelation Date of This Policy* MM slash DD slash YYYY Enter the Reason for Cancelation* Select the Parent:Writing Company Combination for This Policy*ABACUS Group, LLC: ABACUS Group, LLCAdvisors Financial Group, Inc.: Advisors Financial Group, Inc.Advisors Financial Group, Inc.: One AmericaAetna Group: Aetna GroupAetna Group: Aetna Health, Inc.Aetna Group: Aetna Dental, Inc.Aetna Group: Aetna Life Insurance ComapnyAFLAC: AFLACAllied Benefit Insurance: Allied Benefit InsuranceAllied Benefit Insurance: Fidelity Security Life Ins CoAmerican General Life: American General LifeAmerican Heritage: American HeritageAmerican Heritage: AllstateAmerican Heritage: Assuritiy Life Insurance CoAmFirst Insurance Company: AmFirst Insurance CompanyBanner Life: Banner LifeBASIC: BASICBenefit Solutions, Inc.: Benefit Solutions, Inc.BenefitWallet: BenefitWalletBlue Cross Blue Shield of NC: Blue Cross Blue Shield of NCBlue Cross/Blue Shield TN: Blue Cross/Blue Shield TNBoston Mutual Life: Boston Mutual LifeBrighthouse Life Insurance Co: Brighthouse Life Insurance CoCigna Group Insurance: Cigna Group InsuranceCompanion Life Insurance Company: Companion Life Insurance CompanyCrump Insurances Services: Crump Insurances ServicesCrump Insurances Services: AIG Life Insurance Co.Crump Insurances Services: PrudentialCrump Insurances Services: Lincoln National Life Insurance CompanyDelta Dental: Delta DentalDominion Dental Services USA, Inc.: Dominion Dental Services USA, Inc.EyeMed Ins: EyeMed InsFidelity Life: Fidelity LifeFirst National Brokerage Group: First National Brokerage GroupFirst National Brokerage Group: TrigonFirst National Brokerage Group: American General Life InsuranceFirst National Brokerage Group: Anthem HealthPlans of VirginiaFirst National Brokerage Group: Cotton States Life InsuranceFirst National Brokerage Group: Prudential FinancialFirst National Brokerage Group: Shenandoah Life Insurance CompanyFlexible Benefit Administrators: Flexible Benefit AdministratorsFlores & Associates, LLC: Flores & Associates, LLCFort Dearborn Life: Fort Dearborn LifeFurther: FurtherGenworth Life & Annuity Insurance Company: Genworth Life & Annuity Insurance CompanyGenworth Life & Annuity Insurance Company: Colonial GroupGenworth Life & Annuity Insurance Company: First Colony Life Insurance CompanyGenworth Life & Annuity Insurance Company: First National Brokerage GroupGuardian Life Insurance Company: Guardian Life Insurance CompanyHarleysville Life: Harleysville LifeHealth Equity: Health EquityHealthSavings: HealthSavingsHumana: HumanaiSolved (Infinisource): iSolved (Infinisource)John Hancock Life Insurance Company: John Hancock Life Insurance CompanyLincoln Financial: Lincoln FinancialLincoln Financial: Lincoln National LifeMASA Global: MASA GlobalMet Life: Met LifeMet Life: Travelers Proerty & Casualty GroupMet Life: Mag Mutual Insurance CoMet Life: Metropolitan Life Insurance CoMGIS Companies: MGIS CompaniesMutual of Omaha Insurance Company: Mutual of Omaha Insurance CompanyMutual of Omaha Insurance Company: Mutual of Ohama Insurance Co.Mutual of Omaha Insurance Company: Mony Life insurance Co of AmerOptima Health: Optima Health Ins CoPetersen International Underwriters: Petersen International UnderwritersPiedmont Community Health Plan: Piedmont Community Health PlanPrimeflex Administrative Services: Primeflex Administrative ServicesPrincipal Financial Group, Inc.: Principal Financial Group, Inc.Principal Financial Group, Inc.: Principal National Life Insurance CompanyPrincipal Financial Group, Inc.: Principal Financial GroupPrincipal Financial Group, Inc.: Principal Life Insurance Co.Protective Life Group: Protective Life GroupPrudential Brokerage: Prudential BrokerageReliance Standard Life Insurance Company: Reliance Standard Life Insurance CompanySecurity Life: Security LifeShenandoah Life Insurance Company: Shenandoah Life Insurance CompanySun Life and Health Insurance: Sun Life and Health InsuranceSun Life and Health Insurance: Assurant Employee BenefitsSun Life and Health Insurance: Fortis Benefits Insurance Co.Sun Life and Health Insurance: Sun Life Assurance CompanySymetra Life Insurance Company: Symetra Life Insurance CompanyThe Standard: The StandardTransamerica Life Insurance Company: Transamerica Life Insurance CompanyTrue North: True NorthTrue North: Assurant HealthTrue North: TransamericaUnited Concordia: United ConcordiaUnited Healthcare: United HealthcareUNUM Provident: UNUM ProvidentUS Able Life: US Able LifeVested Health (The Health Plan): Vested Health (The Health Plan)Vision Service Plan: Vision Service PlanWell Point, Inc.: Well Point, Inc.Well Point, Inc.: Anthem Health Plans of VirginiaWell Point, Inc.: Anthem Life Insurance CompanyWell Point, Inc.: Anthem Blue Cross Blue ShieldOther Not ListedSpecify Parent and Writing Company Combination for This Policy* Enter Negotiated Commission Percentage*You may need to back into this by dividing the estimated revenue by the estimated premium. Enter the Annual Estimated Premium for This Policy* Enter the Annual Estimated Revenue for This Policy*Enter the name of the Account Manager/Representative for This Policy* Enter the name of the Producer/Executive for This Policy* Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.Enter Producer Commission*Enter the name of the 2nd Producer/Executive for This Policy Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.Enter 2nd Producer CommissionEnter the name of the 3rd Producer/Executive for This Policy Enter 3rd Producer CommissionEnter the name of the Broker for This Policy Enter Broker Commission Information for 5th PolicyIs this a rewrite?* Yes No If this is a new company or policy replacing an existing policy choose YES.Enter the expiring policy number.* Choose the line of business for this policy.*Line of BusinessAccidentCancerCritical IllnessGroup LifeGroup DentalGroup Long Term CareGroup LTDGroup Medical HealthGroup STDGroup VisionHospital IndemnityIndividual DisabilityIndividual DentalIndividual DentalIndividual LifeIndividual Long Term CareIndividual MedicalIndividual VisionMASAMedicare SupplementMiscellaneous BenefitsUniversal LifeVoluntary LTDVoluntary STDVoluntary ProductsVoluntary Term LifeWhole LifePolicy Number* Enter the Effective Date of This Policy* MM slash DD slash YYYY Enter the Expiration Date of This Policy* MM slash DD slash YYYY Enter the Cancelation Date of This Policy* MM slash DD slash YYYY Enter the Reason for Cancelation* Select the Parent:Writing Company Combination for This Policy*ABACUS Group, LLC: ABACUS Group, LLCAdvisors Financial Group, Inc.: Advisors Financial Group, Inc.Advisors Financial Group, Inc.: One AmericaAetna Group: Aetna GroupAetna Group: Aetna Health, Inc.Aetna Group: Aetna Dental, Inc.Aetna Group: Aetna Life Insurance ComapnyAFLAC: AFLACAllied Benefit Insurance: Allied Benefit InsuranceAllied Benefit Insurance: Fidelity Security Life Ins CoAmerican General Life: American General LifeAmerican Heritage: American HeritageAmerican Heritage: AllstateAmerican Heritage: Assuritiy Life Insurance CoAmFirst Insurance Company: AmFirst Insurance CompanyBanner Life: Banner LifeBASIC: BASICBenefit Solutions, Inc.: Benefit Solutions, Inc.BenefitWallet: BenefitWalletBlue Cross Blue Shield of NC: Blue Cross Blue Shield of NCBlue Cross/Blue Shield TN: Blue Cross/Blue Shield TNBoston Mutual Life: Boston Mutual LifeBrighthouse Life Insurance Co: Brighthouse Life Insurance CoCigna Group Insurance: Cigna Group InsuranceCompanion Life Insurance Company: Companion Life Insurance CompanyCrump Insurances Services: Crump Insurances ServicesCrump Insurances Services: AIG Life Insurance Co.Crump Insurances Services: PrudentialCrump Insurances Services: Lincoln National Life Insurance CompanyDelta Dental: Delta DentalDominion Dental Services USA, Inc.: Dominion Dental Services USA, Inc.EyeMed Ins: EyeMed InsFidelity Life: Fidelity LifeFirst National Brokerage Group: First National Brokerage GroupFirst National Brokerage Group: TrigonFirst National Brokerage Group: American General Life InsuranceFirst National Brokerage Group: Anthem HealthPlans of VirginiaFirst National Brokerage Group: Cotton States Life InsuranceFirst National Brokerage Group: Prudential FinancialFirst National Brokerage Group: Shenandoah Life Insurance CompanyFlexible Benefit Administrators: Flexible Benefit AdministratorsFlores & Associates, LLC: Flores & Associates, LLCFort Dearborn Life: Fort Dearborn LifeFurther: FurtherGenworth Life & Annuity Insurance Company: Genworth Life & Annuity Insurance CompanyGenworth Life & Annuity Insurance Company: Colonial GroupGenworth Life & Annuity Insurance Company: First Colony Life Insurance CompanyGenworth Life & Annuity Insurance Company: First National Brokerage GroupGuardian Life Insurance Company: Guardian Life Insurance CompanyHarleysville Life: Harleysville LifeHealth Equity: Health EquityHealthSavings: HealthSavingsHumana: HumanaiSolved (Infinisource): iSolved (Infinisource)John Hancock Life Insurance Company: John Hancock Life Insurance CompanyLincoln Financial: Lincoln FinancialLincoln Financial: Lincoln National LifeMASA Global: MASA GlobalMet Life: Met LifeMet Life: Travelers Proerty & Casualty GroupMet Life: Mag Mutual Insurance CoMet Life: Metropolitan Life Insurance CoMGIS Companies: MGIS CompaniesMutual of Omaha Insurance Company: Mutual of Omaha Insurance CompanyMutual of Omaha Insurance Company: Mutual of Ohama Insurance Co.Mutual of Omaha Insurance Company: Mony Life insurance Co of AmerOptima Health: Optima Health Ins CoPetersen International Underwriters: Petersen International UnderwritersPiedmont Community Health Plan: Piedmont Community Health PlanPrimeflex Administrative Services: Primeflex Administrative ServicesPrincipal Financial Group, Inc.: Principal Financial Group, Inc.Principal Financial Group, Inc.: Principal National Life Insurance CompanyPrincipal Financial Group, Inc.: Principal Financial GroupPrincipal Financial Group, Inc.: Principal Life Insurance Co.Protective Life Group: Protective Life GroupPrudential Brokerage: Prudential BrokerageReliance Standard Life Insurance Company: Reliance Standard Life Insurance CompanySecurity Life: Security LifeShenandoah Life Insurance Company: Shenandoah Life Insurance CompanySun Life and Health Insurance: Sun Life and Health InsuranceSun Life and Health Insurance: Assurant Employee BenefitsSun Life and Health Insurance: Fortis Benefits Insurance Co.Sun Life and Health Insurance: Sun Life Assurance CompanySymetra Life Insurance Company: Symetra Life Insurance CompanyThe Standard: The StandardTransamerica Life Insurance Company: Transamerica Life Insurance CompanyTrue North: True NorthTrue North: Assurant HealthTrue North: TransamericaUnited Concordia: United ConcordiaUnited Healthcare: United HealthcareUNUM Provident: UNUM ProvidentUS Able Life: US Able LifeVested Health (The Health Plan): Vested Health (The Health Plan)Vision Service Plan: Vision Service PlanWell Point, Inc.: Well Point, Inc.Well Point, Inc.: Anthem Health Plans of VirginiaWell Point, Inc.: Anthem Life Insurance CompanyWell Point, Inc.: Anthem Blue Cross Blue ShieldOther Not ListedSpecify Parent and Writing Company Combination for This Policy* Enter Negotiated Commission Percentage*You may need to back into this by dividing the estimated revenue by the estimated premium. Enter the Annual Estimated Premium for This Policy* Enter the Annual Estimated Revenue for This Policy*Enter the name of the Account Manager/Representative for This Policy* Enter the name of the Producer/Executive for This Policy* Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.Enter Producer Commission*Enter the name of the 2nd Producer/Executive for This Policy Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.Enter 2nd Producer CommissionEnter the name of the 3rd Producer/Executive for This Policy Enter 3rd Producer CommissionEnter the name of the Broker for This Policy Enter Broker Commission Information for 6th PolicyIs this a rewrite?* Yes No If this is a new company or policy replacing an existing policy choose YES.Enter the expiring policy number.* Choose the line of business for this policy.*Line of BusinessAccidentCancerCritical IllnessGroup LifeGroup DentalGroup Long Term CareGroup LTDGroup Medical HealthGroup STDGroup VisionHospital IndemnityIndividual DisabilityIndividual DentalIndividual DentalIndividual LifeIndividual Long Term CareIndividual MedicalIndividual VisionMASAMedicare SupplementMiscellaneous BenefitsUniversal LifeVoluntary LTDVoluntary STDVoluntary ProductsVoluntary Term LifeWhole LifePolicy Number* Enter the Effective Date of This Policy* MM slash DD slash YYYY Enter the Expiration Date of This Policy* MM slash DD slash YYYY Enter the Cancelation Date of This Policy* MM slash DD slash YYYY Enter the Reason for Cancelation* Select the Parent:Writing Company Combination for This Policy*ABACUS Group, LLC: ABACUS Group, LLCAdvisors Financial Group, Inc.: Advisors Financial Group, Inc.Advisors Financial Group, Inc.: One AmericaAetna Group: Aetna GroupAetna Group: Aetna Health, Inc.Aetna Group: Aetna Dental, Inc.Aetna Group: Aetna Life Insurance ComapnyAFLAC: AFLACAllied Benefit Insurance: Allied Benefit InsuranceAllied Benefit Insurance: Fidelity Security Life Ins CoAmerican General Life: American General LifeAmerican Heritage: American HeritageAmerican Heritage: AllstateAmerican Heritage: Assuritiy Life Insurance CoAmFirst Insurance Company: AmFirst Insurance CompanyBanner Life: Banner LifeBASIC: BASICBenefit Solutions, Inc.: Benefit Solutions, Inc.BenefitWallet: BenefitWalletBlue Cross Blue Shield of NC: Blue Cross Blue Shield of NCBlue Cross/Blue Shield TN: Blue Cross/Blue Shield TNBoston Mutual Life: Boston Mutual LifeBrighthouse Life Insurance Co: Brighthouse Life Insurance CoCigna Group Insurance: Cigna Group InsuranceCompanion Life Insurance Company: Companion Life Insurance CompanyCrump Insurances Services: Crump Insurances ServicesCrump Insurances Services: AIG Life Insurance Co.Crump Insurances Services: PrudentialCrump Insurances Services: Lincoln National Life Insurance CompanyDelta Dental: Delta DentalDominion Dental Services USA, Inc.: Dominion Dental Services USA, Inc.EyeMed Ins: EyeMed InsFidelity Life: Fidelity LifeFirst National Brokerage Group: First National Brokerage GroupFirst National Brokerage Group: TrigonFirst National Brokerage Group: American General Life InsuranceFirst National Brokerage Group: Anthem HealthPlans of VirginiaFirst National Brokerage Group: Cotton States Life InsuranceFirst National Brokerage Group: Prudential FinancialFirst National Brokerage Group: Shenandoah Life Insurance CompanyFlexible Benefit Administrators: Flexible Benefit AdministratorsFlores & Associates, LLC: Flores & Associates, LLCFort Dearborn Life: Fort Dearborn LifeFurther: FurtherGenworth Life & Annuity Insurance Company: Genworth Life & Annuity Insurance CompanyGenworth Life & Annuity Insurance Company: Colonial GroupGenworth Life & Annuity Insurance Company: First Colony Life Insurance CompanyGenworth Life & Annuity Insurance Company: First National Brokerage GroupGuardian Life Insurance Company: Guardian Life Insurance CompanyHarleysville Life: Harleysville LifeHealth Equity: Health EquityHealthSavings: HealthSavingsHumana: HumanaiSolved (Infinisource): iSolved (Infinisource)John Hancock Life Insurance Company: John Hancock Life Insurance CompanyLincoln Financial: Lincoln FinancialLincoln Financial: Lincoln National LifeMASA Global: MASA GlobalMet Life: Met LifeMet Life: Travelers Proerty & Casualty GroupMet Life: Mag Mutual Insurance CoMet Life: Metropolitan Life Insurance CoMGIS Companies: MGIS CompaniesMutual of Omaha Insurance Company: Mutual of Omaha Insurance CompanyMutual of Omaha Insurance Company: Mutual of Ohama Insurance Co.Mutual of Omaha Insurance Company: Mony Life insurance Co of AmerOptima Health: Optima Health Ins CoPetersen International Underwriters: Petersen International UnderwritersPiedmont Community Health Plan: Piedmont Community Health PlanPrimeflex Administrative Services: Primeflex Administrative ServicesPrincipal Financial Group, Inc.: Principal Financial Group, Inc.Principal Financial Group, Inc.: Principal National Life Insurance CompanyPrincipal Financial Group, Inc.: Principal Financial GroupPrincipal Financial Group, Inc.: Principal Life Insurance Co.Protective Life Group: Protective Life GroupPrudential Brokerage: Prudential BrokerageReliance Standard Life Insurance Company: Reliance Standard Life Insurance CompanySecurity Life: Security LifeShenandoah Life Insurance Company: Shenandoah Life Insurance CompanySun Life and Health Insurance: Sun Life and Health InsuranceSun Life and Health Insurance: Assurant Employee BenefitsSun Life and Health Insurance: Fortis Benefits Insurance Co.Sun Life and Health Insurance: Sun Life Assurance CompanySymetra Life Insurance Company: Symetra Life Insurance CompanyThe Standard: The StandardTransamerica Life Insurance Company: Transamerica Life Insurance CompanyTrue North: True NorthTrue North: Assurant HealthTrue North: TransamericaUnited Concordia: United ConcordiaUnited Healthcare: United HealthcareUNUM Provident: UNUM ProvidentUS Able Life: US Able LifeVested Health (The Health Plan): Vested Health (The Health Plan)Vision Service Plan: Vision Service PlanWell Point, Inc.: Well Point, Inc.Well Point, Inc.: Anthem Health Plans of VirginiaWell Point, Inc.: Anthem Life Insurance CompanyWell Point, Inc.: Anthem Blue Cross Blue ShieldOther Not ListedSpecify Parent and Writing Company Combination for This Policy* Enter Negotiated Commission Percentage*You may need to back into this by dividing the estimated revenue by the estimated premium. Enter the Annual Estimated Premium for This Policy* Enter the Annual Estimated Revenue for This Policy*Enter the name of the Account Manager/Representative for This Policy* Enter the name of the Producer/Executive for This Policy* Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.Enter Producer Commission*Enter the name of the 2nd Producer/Executive for This Policy Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.Enter 2nd Producer CommissionEnter the name of the 3rd Producer/Executive for This Policy Enter 3rd Producer CommissionEnter the name of the Broker for This Policy Enter Broker Commission Information for 7th PolicyIs this a rewrite?* Yes No If this is a new company or policy replacing an existing policy choose YES.Enter the expiring policy number.* Choose the line of business for this policy.*Line of BusinessAccidentCancerCritical IllnessGroup LifeGroup DentalGroup Long Term CareGroup LTDGroup Medical HealthGroup STDGroup VisionHospital IndemnityIndividual DisabilityIndividual DentalIndividual DentalIndividual LifeIndividual Long Term CareIndividual MedicalIndividual VisionMASAMedicare SupplementMiscellaneous BenefitsUniversal LifeVoluntary LTDVoluntary STDVoluntary ProductsVoluntary Term LifeWhole LifePolicy Number* Enter the Effective Date of This Policy* MM slash DD slash YYYY Enter the Expiration Date of This Policy* MM slash DD slash YYYY Enter the Cancelation Date of This Policy* MM slash DD slash YYYY Enter the Reason for Cancelation* Select the Parent:Writing Company Combination for This Policy*ABACUS Group, LLC: ABACUS Group, LLCAdvisors Financial Group, Inc.: Advisors Financial Group, Inc.Advisors Financial Group, Inc.: One AmericaAetna Group: Aetna GroupAetna Group: Aetna Health, Inc.Aetna Group: Aetna Dental, Inc.Aetna Group: Aetna Life Insurance ComapnyAFLAC: AFLACAllied Benefit Insurance: Allied Benefit InsuranceAllied Benefit Insurance: Fidelity Security Life Ins CoAmerican General Life: American General LifeAmerican Heritage: American HeritageAmerican Heritage: AllstateAmerican Heritage: Assuritiy Life Insurance CoAmFirst Insurance Company: AmFirst Insurance CompanyBanner Life: Banner LifeBASIC: BASICBenefit Solutions, Inc.: Benefit Solutions, Inc.BenefitWallet: BenefitWalletBlue Cross Blue Shield of NC: Blue Cross Blue Shield of NCBlue Cross/Blue Shield TN: Blue Cross/Blue Shield TNBoston Mutual Life: Boston Mutual LifeBrighthouse Life Insurance Co: Brighthouse Life Insurance CoCigna Group Insurance: Cigna Group InsuranceCompanion Life Insurance Company: Companion Life Insurance CompanyCrump Insurances Services: Crump Insurances ServicesCrump Insurances Services: AIG Life Insurance Co.Crump Insurances Services: PrudentialCrump Insurances Services: Lincoln National Life Insurance CompanyDelta Dental: Delta DentalDominion Dental Services USA, Inc.: Dominion Dental Services USA, Inc.EyeMed Ins: EyeMed InsFidelity Life: Fidelity LifeFirst National Brokerage Group: First National Brokerage GroupFirst National Brokerage Group: TrigonFirst National Brokerage Group: American General Life InsuranceFirst National Brokerage Group: Anthem HealthPlans of VirginiaFirst National Brokerage Group: Cotton States Life InsuranceFirst National Brokerage Group: Prudential FinancialFirst National Brokerage Group: Shenandoah Life Insurance CompanyFlexible Benefit Administrators: Flexible Benefit AdministratorsFlores & Associates, LLC: Flores & Associates, LLCFort Dearborn Life: Fort Dearborn LifeFurther: FurtherGenworth Life & Annuity Insurance Company: Genworth Life & Annuity Insurance CompanyGenworth Life & Annuity Insurance Company: Colonial GroupGenworth Life & Annuity Insurance Company: First Colony Life Insurance CompanyGenworth Life & Annuity Insurance Company: First National Brokerage GroupGuardian Life Insurance Company: Guardian Life Insurance CompanyHarleysville Life: Harleysville LifeHealth Equity: Health EquityHealthSavings: HealthSavingsHumana: HumanaiSolved (Infinisource): iSolved (Infinisource)John Hancock Life Insurance Company: John Hancock Life Insurance CompanyLincoln Financial: Lincoln FinancialLincoln Financial: Lincoln National LifeMASA Global: MASA GlobalMet Life: Met LifeMet Life: Travelers Proerty & Casualty GroupMet Life: Mag Mutual Insurance CoMet Life: Metropolitan Life Insurance CoMGIS Companies: MGIS CompaniesMutual of Omaha Insurance Company: Mutual of Omaha Insurance CompanyMutual of Omaha Insurance Company: Mutual of Ohama Insurance Co.Mutual of Omaha Insurance Company: Mony Life insurance Co of AmerOptima Health: Optima Health Ins CoPetersen International Underwriters: Petersen International UnderwritersPiedmont Community Health Plan: Piedmont Community Health PlanPrimeflex Administrative Services: Primeflex Administrative ServicesPrincipal Financial Group, Inc.: Principal Financial Group, Inc.Principal Financial Group, Inc.: Principal National Life Insurance CompanyPrincipal Financial Group, Inc.: Principal Financial GroupPrincipal Financial Group, Inc.: Principal Life Insurance Co.Protective Life Group: Protective Life GroupPrudential Brokerage: Prudential BrokerageReliance Standard Life Insurance Company: Reliance Standard Life Insurance CompanySecurity Life: Security LifeShenandoah Life Insurance Company: Shenandoah Life Insurance CompanySun Life and Health Insurance: Sun Life and Health InsuranceSun Life and Health Insurance: Assurant Employee BenefitsSun Life and Health Insurance: Fortis Benefits Insurance Co.Sun Life and Health Insurance: Sun Life Assurance CompanySymetra Life Insurance Company: Symetra Life Insurance CompanyThe Standard: The StandardTransamerica Life Insurance Company: Transamerica Life Insurance CompanyTrue North: True NorthTrue North: Assurant HealthTrue North: TransamericaUnited Concordia: United ConcordiaUnited Healthcare: United HealthcareUNUM Provident: UNUM ProvidentUS Able Life: US Able LifeVested Health (The Health Plan): Vested Health (The Health Plan)Vision Service Plan: Vision Service PlanWell Point, Inc.: Well Point, Inc.Well Point, Inc.: Anthem Health Plans of VirginiaWell Point, Inc.: Anthem Life Insurance CompanyWell Point, Inc.: Anthem Blue Cross Blue ShieldOther Not ListedSpecify Parent and Writing Company Combination for This Policy* Enter Negotiated Commission Percentage*You may need to back into this by dividing the estimated revenue by the estimated premium. Enter the Annual Estimated Premium for This Policy* Enter the Annual Estimated Revenue for This Policy*Enter the name of the Account Manager/Representative for This Policy* Enter the name of the Producer/Executive for This Policy* Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.Enter Producer Commission*Enter the name of the 2nd Producer/Executive for This Policy Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.Enter 2nd Producer CommissionEnter the name of the 3rd Producer/Executive for This Policy Enter 3rd Producer CommissionEnter the name of the Broker for This Policy Enter Broker Commission Information for 8th PolicyIs this a rewrite?* Yes No If this is a new company or policy replacing an existing policy choose YES.Enter the expiring policy number.* Choose the line of business for this policy.*Line of BusinessAccidentCancerCritical IllnessGroup LifeGroup DentalGroup Long Term CareGroup LTDGroup Medical HealthGroup STDGroup VisionHospital IndemnityIndividual DisabilityIndividual DentalIndividual DentalIndividual LifeIndividual Long Term CareIndividual MedicalIndividual VisionMASAMedicare SupplementMiscellaneous BenefitsUniversal LifeVoluntary LTDVoluntary STDVoluntary ProductsVoluntary Term LifeWhole LifePolicy Number* Enter the Effective Date of This Policy* MM slash DD slash YYYY Enter the Expiration Date of This Policy* MM slash DD slash YYYY Enter the Cancelation Date of This Policy* MM slash DD slash YYYY Enter the Reason for Cancelation* Select the Parent:Writing Company Combination for This Policy*ABACUS Group, LLC: ABACUS Group, LLCAdvisors Financial Group, Inc.: Advisors Financial Group, Inc.Advisors Financial Group, Inc.: One AmericaAetna Group: Aetna GroupAetna Group: Aetna Health, Inc.Aetna Group: Aetna Dental, Inc.Aetna Group: Aetna Life Insurance ComapnyAFLAC: AFLACAllied Benefit Insurance: Allied Benefit InsuranceAllied Benefit Insurance: Fidelity Security Life Ins CoAmerican General Life: American General LifeAmerican Heritage: American HeritageAmerican Heritage: AllstateAmerican Heritage: Assuritiy Life Insurance CoAmFirst Insurance Company: AmFirst Insurance CompanyBanner Life: Banner LifeBASIC: BASICBenefit Solutions, Inc.: Benefit Solutions, Inc.BenefitWallet: BenefitWalletBlue Cross Blue Shield of NC: Blue Cross Blue Shield of NCBlue Cross/Blue Shield TN: Blue Cross/Blue Shield TNBoston Mutual Life: Boston Mutual LifeBrighthouse Life Insurance Co: Brighthouse Life Insurance CoCigna Group Insurance: Cigna Group InsuranceCompanion Life Insurance Company: Companion Life Insurance CompanyCrump Insurances Services: Crump Insurances ServicesCrump Insurances Services: AIG Life Insurance Co.Crump Insurances Services: PrudentialCrump Insurances Services: Lincoln National Life Insurance CompanyDelta Dental: Delta DentalDominion Dental Services USA, Inc.: Dominion Dental Services USA, Inc.EyeMed Ins: EyeMed InsFidelity Life: Fidelity LifeFirst National Brokerage Group: First National Brokerage GroupFirst National Brokerage Group: TrigonFirst National Brokerage Group: American General Life InsuranceFirst National Brokerage Group: Anthem HealthPlans of VirginiaFirst National Brokerage Group: Cotton States Life InsuranceFirst National Brokerage Group: Prudential FinancialFirst National Brokerage Group: Shenandoah Life Insurance CompanyFlexible Benefit Administrators: Flexible Benefit AdministratorsFlores & Associates, LLC: Flores & Associates, LLCFort Dearborn Life: Fort Dearborn LifeFurther: FurtherGenworth Life & Annuity Insurance Company: Genworth Life & Annuity Insurance CompanyGenworth Life & Annuity Insurance Company: Colonial GroupGenworth Life & Annuity Insurance Company: First Colony Life Insurance CompanyGenworth Life & Annuity Insurance Company: First National Brokerage GroupGuardian Life Insurance Company: Guardian Life Insurance CompanyHarleysville Life: Harleysville LifeHealth Equity: Health EquityHealthSavings: HealthSavingsHumana: HumanaiSolved (Infinisource): iSolved (Infinisource)John Hancock Life Insurance Company: John Hancock Life Insurance CompanyLincoln Financial: Lincoln FinancialLincoln Financial: Lincoln National LifeMASA Global: MASA GlobalMet Life: Met LifeMet Life: Travelers Proerty & Casualty GroupMet Life: Mag Mutual Insurance CoMet Life: Metropolitan Life Insurance CoMGIS Companies: MGIS CompaniesMutual of Omaha Insurance Company: Mutual of Omaha Insurance CompanyMutual of Omaha Insurance Company: Mutual of Ohama Insurance Co.Mutual of Omaha Insurance Company: Mony Life insurance Co of AmerOptima Health: Optima Health Ins CoPetersen International Underwriters: Petersen International UnderwritersPiedmont Community Health Plan: Piedmont Community Health PlanPrimeflex Administrative Services: Primeflex Administrative ServicesPrincipal Financial Group, Inc.: Principal Financial Group, Inc.Principal Financial Group, Inc.: Principal National Life Insurance CompanyPrincipal Financial Group, Inc.: Principal Financial GroupPrincipal Financial Group, Inc.: Principal Life Insurance Co.Protective Life Group: Protective Life GroupPrudential Brokerage: Prudential BrokerageReliance Standard Life Insurance Company: Reliance Standard Life Insurance CompanySecurity Life: Security LifeShenandoah Life Insurance Company: Shenandoah Life Insurance CompanySun Life and Health Insurance: Sun Life and Health InsuranceSun Life and Health Insurance: Assurant Employee BenefitsSun Life and Health Insurance: Fortis Benefits Insurance Co.Sun Life and Health Insurance: Sun Life Assurance CompanySymetra Life Insurance Company: Symetra Life Insurance CompanyThe Standard: The StandardTransamerica Life Insurance Company: Transamerica Life Insurance CompanyTrue North: True NorthTrue North: Assurant HealthTrue North: TransamericaUnited Concordia: United ConcordiaUnited Healthcare: United HealthcareUNUM Provident: UNUM ProvidentUS Able Life: US Able LifeVested Health (The Health Plan): Vested Health (The Health Plan)Vision Service Plan: Vision Service PlanWell Point, Inc.: Well Point, Inc.Well Point, Inc.: Anthem Health Plans of VirginiaWell Point, Inc.: Anthem Life Insurance CompanyWell Point, Inc.: Anthem Blue Cross Blue ShieldOther Not ListedSpecify Parent and Writing Company Combination for This Policy* Enter Negotiated Commission Percentage*You may need to back into this by dividing the estimated revenue by the estimated premium. Enter the Annual Estimated Premium for This Policy* Enter the Annual Estimated Revenue for This Policy*Enter the name of the Account Manager/Representative for This Policy* Enter the name of the Producer/Executive for This Policy* Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.Enter Producer Commission*Enter the name of the 2nd Producer/Executive for This Policy Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.Enter 2nd Producer CommissionEnter the name of the 3rd Producer/Executive for This Policy Enter 3rd Producer CommissionEnter the name of the Broker for This Policy Enter Broker Commission Information for 9th PolicyIs this a rewrite?* Yes No If this is a new company or policy replacing an existing policy choose YES.Enter the expiring policy number.* Choose the line of business for this policy.*Line of BusinessAccidentCancerCritical IllnessGroup LifeGroup DentalGroup Long Term CareGroup LTDGroup Medical HealthGroup STDGroup VisionHospital IndemnityIndividual DisabilityIndividual DentalIndividual DentalIndividual LifeIndividual Long Term CareIndividual MedicalIndividual VisionMASAMedicare SupplementMiscellaneous BenefitsUniversal LifeVoluntary LTDVoluntary STDVoluntary ProductsVoluntary Term LifeWhole LifePolicy Number* Enter the Effective Date of This Policy* MM slash DD slash YYYY Enter the Expiration Date of This Policy* MM slash DD slash YYYY Enter the Cancelation Date of This Policy* MM slash DD slash YYYY Enter the Reason for Cancelation* Select the Parent:Writing Company Combination for This Policy*ABACUS Group, LLC: ABACUS Group, LLCAdvisors Financial Group, Inc.: Advisors Financial Group, Inc.Advisors Financial Group, Inc.: One AmericaAetna Group: Aetna GroupAetna Group: Aetna Health, Inc.Aetna Group: Aetna Dental, Inc.Aetna Group: Aetna Life Insurance ComapnyAFLAC: AFLACAllied Benefit Insurance: Allied Benefit InsuranceAllied Benefit Insurance: Fidelity Security Life Ins CoAmerican General Life: American General LifeAmerican Heritage: American HeritageAmerican Heritage: AllstateAmerican Heritage: Assuritiy Life Insurance CoAmFirst Insurance Company: AmFirst Insurance CompanyBanner Life: Banner LifeBASIC: BASICBenefit Solutions, Inc.: Benefit Solutions, Inc.BenefitWallet: BenefitWalletBlue Cross Blue Shield of NC: Blue Cross Blue Shield of NCBlue Cross/Blue Shield TN: Blue Cross/Blue Shield TNBoston Mutual Life: Boston Mutual LifeBrighthouse Life Insurance Co: Brighthouse Life Insurance CoCigna Group Insurance: Cigna Group InsuranceCompanion Life Insurance Company: Companion Life Insurance CompanyCrump Insurances Services: Crump Insurances ServicesCrump Insurances Services: AIG Life Insurance Co.Crump Insurances Services: PrudentialCrump Insurances Services: Lincoln National Life Insurance CompanyDelta Dental: Delta DentalDominion Dental Services USA, Inc.: Dominion Dental Services USA, Inc.EyeMed Ins: EyeMed InsFidelity Life: Fidelity LifeFirst National Brokerage Group: First National Brokerage GroupFirst National Brokerage Group: TrigonFirst National Brokerage Group: American General Life InsuranceFirst National Brokerage Group: Anthem HealthPlans of VirginiaFirst National Brokerage Group: Cotton States Life InsuranceFirst National Brokerage Group: Prudential FinancialFirst National Brokerage Group: Shenandoah Life Insurance CompanyFlexible Benefit Administrators: Flexible Benefit AdministratorsFlores & Associates, LLC: Flores & Associates, LLCFort Dearborn Life: Fort Dearborn LifeFurther: FurtherGenworth Life & Annuity Insurance Company: Genworth Life & Annuity Insurance CompanyGenworth Life & Annuity Insurance Company: Colonial GroupGenworth Life & Annuity Insurance Company: First Colony Life Insurance CompanyGenworth Life & Annuity Insurance Company: First National Brokerage GroupGuardian Life Insurance Company: Guardian Life Insurance CompanyHarleysville Life: Harleysville LifeHealth Equity: Health EquityHealthSavings: HealthSavingsHumana: HumanaiSolved (Infinisource): iSolved (Infinisource)John Hancock Life Insurance Company: John Hancock Life Insurance CompanyLincoln Financial: Lincoln FinancialLincoln Financial: Lincoln National LifeMASA Global: MASA GlobalMet Life: Met LifeMet Life: Travelers Proerty & Casualty GroupMet Life: Mag Mutual Insurance CoMet Life: Metropolitan Life Insurance CoMGIS Companies: MGIS CompaniesMutual of Omaha Insurance Company: Mutual of Omaha Insurance CompanyMutual of Omaha Insurance Company: Mutual of Ohama Insurance Co.Mutual of Omaha Insurance Company: Mony Life insurance Co of AmerOptima Health: Optima Health Ins CoPetersen International Underwriters: Petersen International UnderwritersPiedmont Community Health Plan: Piedmont Community Health PlanPrimeflex Administrative Services: Primeflex Administrative ServicesPrincipal Financial Group, Inc.: Principal Financial Group, Inc.Principal Financial Group, Inc.: Principal National Life Insurance CompanyPrincipal Financial Group, Inc.: Principal Financial GroupPrincipal Financial Group, Inc.: Principal Life Insurance Co.Protective Life Group: Protective Life GroupPrudential Brokerage: Prudential BrokerageReliance Standard Life Insurance Company: Reliance Standard Life Insurance CompanySecurity Life: Security LifeShenandoah Life Insurance Company: Shenandoah Life Insurance CompanySun Life and Health Insurance: Sun Life and Health InsuranceSun Life and Health Insurance: Assurant Employee BenefitsSun Life and Health Insurance: Fortis Benefits Insurance Co.Sun Life and Health Insurance: Sun Life Assurance CompanySymetra Life Insurance Company: Symetra Life Insurance CompanyThe Standard: The StandardTransamerica Life Insurance Company: Transamerica Life Insurance CompanyTrue North: True NorthTrue North: Assurant HealthTrue North: TransamericaUnited Concordia: United ConcordiaUnited Healthcare: United HealthcareUNUM Provident: UNUM ProvidentUS Able Life: US Able LifeVested Health (The Health Plan): Vested Health (The Health Plan)Vision Service Plan: Vision Service PlanWell Point, Inc.: Well Point, Inc.Well Point, Inc.: Anthem Health Plans of VirginiaWell Point, Inc.: Anthem Life Insurance CompanyWell Point, Inc.: Anthem Blue Cross Blue ShieldOther Not ListedSpecify Parent and Writing Company Combination for This Policy* Enter Negotiated Commission Percentage*You may need to back into this by dividing the estimated revenue by the estimated premium. Enter the Annual Estimated Premium for This Policy* Enter the Annual Estimated Revenue for This Policy*Enter the name of the Account Manager/Representative for This Policy* Enter the name of the Producer/Executive for This Policy* Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.Enter Producer Commission*Enter the name of the 2nd Producer/Executive for This Policy Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.Enter 2nd Producer CommissionEnter the name of the 3rd Producer/Executive for This Policy Enter 3rd Producer CommissionEnter the name of the Broker for This Policy Enter Broker Commission Information for 10th PolicyIs this a rewrite?* Yes No If this is a new company or policy replacing an existing policy choose YES.Enter the expiring policy number.* Choose the line of business for this policy.*Line of BusinessAccidentCancerCritical IllnessGroup LifeGroup DentalGroup Long Term CareGroup LTDGroup Medical HealthGroup STDGroup VisionHospital IndemnityIndividual DisabilityIndividual DentalIndividual DentalIndividual LifeIndividual Long Term CareIndividual MedicalIndividual VisionMASAMedicare SupplementMiscellaneous BenefitsUniversal LifeVoluntary LTDVoluntary STDVoluntary ProductsVoluntary Term LifeWhole LifePolicy Number* Enter the Effective Date of This Policy* MM slash DD slash YYYY Enter the Expiration Date of This Policy* MM slash DD slash YYYY Enter the Cancelation Date of This Policy* MM slash DD slash YYYY Enter the Reason for Cancelation* Select the Parent:Writing Company Combination for This Policy*ABACUS Group, LLC: ABACUS Group, LLCAdvisors Financial Group, Inc.: Advisors Financial Group, Inc.Advisors Financial Group, Inc.: One AmericaAetna Group: Aetna GroupAetna Group: Aetna Health, Inc.Aetna Group: Aetna Dental, Inc.Aetna Group: Aetna Life Insurance ComapnyAFLAC: AFLACAllied Benefit Insurance: Allied Benefit InsuranceAllied Benefit Insurance: Fidelity Security Life Ins CoAmerican General Life: American General LifeAmerican Heritage: American HeritageAmerican Heritage: AllstateAmerican Heritage: Assuritiy Life Insurance CoAmFirst Insurance Company: AmFirst Insurance CompanyBanner Life: Banner LifeBASIC: BASICBenefit Solutions, Inc.: Benefit Solutions, Inc.BenefitWallet: BenefitWalletBlue Cross Blue Shield of NC: Blue Cross Blue Shield of NCBlue Cross/Blue Shield TN: Blue Cross/Blue Shield TNBoston Mutual Life: Boston Mutual LifeBrighthouse Life Insurance Co: Brighthouse Life Insurance CoCigna Group Insurance: Cigna Group InsuranceCompanion Life Insurance Company: Companion Life Insurance CompanyCrump Insurances Services: Crump Insurances ServicesCrump Insurances Services: AIG Life Insurance Co.Crump Insurances Services: PrudentialCrump Insurances Services: Lincoln National Life Insurance CompanyDelta Dental: Delta DentalDominion Dental Services USA, Inc.: Dominion Dental Services USA, Inc.EyeMed Ins: EyeMed InsFidelity Life: Fidelity LifeFirst National Brokerage Group: First National Brokerage GroupFirst National Brokerage Group: TrigonFirst National Brokerage Group: American General Life InsuranceFirst National Brokerage Group: Anthem HealthPlans of VirginiaFirst National Brokerage Group: Cotton States Life InsuranceFirst National Brokerage Group: Prudential FinancialFirst National Brokerage Group: Shenandoah Life Insurance CompanyFlexible Benefit Administrators: Flexible Benefit AdministratorsFlores & Associates, LLC: Flores & Associates, LLCFort Dearborn Life: Fort Dearborn LifeFurther: FurtherGenworth Life & Annuity Insurance Company: Genworth Life & Annuity Insurance CompanyGenworth Life & Annuity Insurance Company: Colonial GroupGenworth Life & Annuity Insurance Company: First Colony Life Insurance CompanyGenworth Life & Annuity Insurance Company: First National Brokerage GroupGuardian Life Insurance Company: Guardian Life Insurance CompanyHarleysville Life: Harleysville LifeHealth Equity: Health EquityHealthSavings: HealthSavingsHumana: HumanaiSolved (Infinisource): iSolved (Infinisource)John Hancock Life Insurance Company: John Hancock Life Insurance CompanyLincoln Financial: Lincoln FinancialLincoln Financial: Lincoln National LifeMASA Global: MASA GlobalMet Life: Met LifeMet Life: Travelers Proerty & Casualty GroupMet Life: Mag Mutual Insurance CoMet Life: Metropolitan Life Insurance CoMGIS Companies: MGIS CompaniesMutual of Omaha Insurance Company: Mutual of Omaha Insurance CompanyMutual of Omaha Insurance Company: Mutual of Ohama Insurance Co.Mutual of Omaha Insurance Company: Mony Life insurance Co of AmerOptima Health: Optima Health Ins CoPetersen International Underwriters: Petersen International UnderwritersPiedmont Community Health Plan: Piedmont Community Health PlanPrimeflex Administrative Services: Primeflex Administrative ServicesPrincipal Financial Group, Inc.: Principal Financial Group, Inc.Principal Financial Group, Inc.: Principal National Life Insurance CompanyPrincipal Financial Group, Inc.: Principal Financial GroupPrincipal Financial Group, Inc.: Principal Life Insurance Co.Protective Life Group: Protective Life GroupPrudential Brokerage: Prudential BrokerageReliance Standard Life Insurance Company: Reliance Standard Life Insurance CompanySecurity Life: Security LifeShenandoah Life Insurance Company: Shenandoah Life Insurance CompanySun Life and Health Insurance: Sun Life and Health InsuranceSun Life and Health Insurance: Assurant Employee BenefitsSun Life and Health Insurance: Fortis Benefits Insurance Co.Sun Life and Health Insurance: Sun Life Assurance CompanySymetra Life Insurance Company: Symetra Life Insurance CompanyThe Standard: The StandardTransamerica Life Insurance Company: Transamerica Life Insurance CompanyTrue North: True NorthTrue North: Assurant HealthTrue North: TransamericaUnited Concordia: United ConcordiaUnited Healthcare: United HealthcareUNUM Provident: UNUM ProvidentUS Able Life: US Able LifeVested Health (The Health Plan): Vested Health (The Health Plan)Vision Service Plan: Vision Service PlanWell Point, Inc.: Well Point, Inc.Well Point, Inc.: Anthem Health Plans of VirginiaWell Point, Inc.: Anthem Life Insurance CompanyWell Point, Inc.: Anthem Blue Cross Blue ShieldOther Not ListedSpecify Parent and Writing Company Combination for This Policy* Enter Negotiated Commission Percentage*You may need to back into this by dividing the estimated revenue by the estimated premium. Enter the Annual Estimated Premium for This Policy* Enter the Annual Estimated Revenue for This Policy*Enter the name of the Account Manager/Representative for This Policy* Enter the name of the Producer/Executive for This Policy* Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.Enter Producer Commission*Enter the name of the 2nd Producer/Executive for This Policy Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.Enter 2nd Producer CommissionEnter the name of the 3rd Producer/Executive for This Policy Enter 3rd Producer CommissionEnter the name of the Broker for This Policy Enter Broker Commission Describe required changes below.*