once the page loads, select “new user?” to register for … authorization please read this...
TRANSCRIPT
Contracting with Neishloss & Fleming, Inc. is now easier than ever! Neishloss & Fleming, Inc. offers the services of SureLC
for contracting with various Health, Life, and Senior carriers.
With the exception of a few carriers, you will be able to contract for multiple carriers in about eight minutes or less with
the click of a mouse. You can complete your agent profile and submit your complete contracting requests to Neishloss &
Fleming, Inc. without having to fill out a single piece of paper!
To begin contracting through SureLC, simply follow the link below to get started:
https://surelc.surancebay.com/sbweb/agency/283
Once the page loads, select “New User?” to register for SureLC
(NOTE: If you have already registered for SureLC and you are
adding a carrier to your profile, simply log in using the Login
and Password that you previously created).
A new page will reload that looks like this:
The only thing that you need to remember is to list
Neishloss & Fleming, Inc. on the Affiliation Line.
You will then enter all of your personal information
into the requested fields, click “Add Me” and
SureLC will pull your information from the NIPR
database. After the data transfer is complete, you
will be able to change/update any of the pre-
populated information as well as upload a copy of
your voided check, proof of E&O insurance,
Signature Page and N&F agent addendum (both
documents are provided in this pack immediately
following this page and must be attached to
SureLC).
If you do not have access to a scanner, please feel free to use the provided fax cover sheet and fax the forms (as well as
a copy of your voided check for EFT) to 412-561-6432 and we will email them to you in PDF format.
At the end of this pack you will find a SureLC FAQ containing additional information on the SureLC online contracting
process.
If you have any questions at all, give us a call at 800-562-7733. We look forward to working with you!
By signing and electronically submitting this form, I am agreeing to contract for the carrier(s) listed above at the stated commission level with
the stated hierarchy.
Date:
I, , would like to be appointed for
Highmark MA through Neishloss & Fleming, Inc. My Commission level for this carrier is
Agent .
Please appoint me for:
Highmark Blue Cross Blue Shield
Should you have any questions, please call me at .
Sincerely,
Agent Name
Carrier Name
Commission Level
Phone Number
Agent Signature
Highmark Blue Shield
Signature Authorization
PLEASE READ THIS AUTHORIZATION, SIGN IN THE BOX BELOW AND
SUBMIT THIS FORM BY FOLLOWING THE INSTRUCTIONS PROVIDED
ON THE COVER PAGE.
I, ____________________________________, hereby authorize
SuranceBay, LLC and its general agency customers (the “Authorized
Parties”) to affix or append a copy of my signature, as set forth below,
to any and all required signature fields on forms and agreements of
any insurance carrier (a “Carrier”) designated by me through the
SureLC software or through any other means, including without
limitation, by e-mail or orally. The Authorized Parties shall be
permitted to complete and submit all such forms and agreements on
my behalf for the purpose of becoming authorized to sell Carrier
insurance products. I hereby release, indemnify and hold harmless the
Authorized Parties against any and all claims, demands, losses,
damages, and causes of action, including expenses, costs and
reasonable attorneys' fees which they may sustain or incur as a result
of carrying out the authority granted hereunder.
By my signature below, I certify that the information I have submitted
to the Authorized Parties is correct to the best of my knowledge and
acknowledge that I have read and reviewed the forms and agreements
which the Authorized Parties have been authorized to affix my
signature. I agree to indemnify and hold any third party harmless from
and against any and all claims, demands, losses, damages, and causes
of action, including expenses, costs and reasonable attorneys' fees
which such third party may incur as a result of its reliance on any form
or agreement bearing my signature pursuant to this authorization.
Please sign in the center of the box below. Please use BLACK ink.
PRODUCERIDXXX
TO: FROM:
Contracting
COMPANY: DATE:
FAX NUMBER: TOTAL NO. OF PAGES INCLUDING COVER:
412-561-6432
RE:
Supporting Documentation for SureLC
URGENT FOR REVIEW PLEASE COMMENT PLEASE REPLY PLEASE RECYCLE
Please find attached my information to complete the SureLC contracting process. I do not have access to a scanner to attach the documents in PDF format. I have included the following documents:
N&F Contracting Addendum SureLC Signature Page Proof of E&O Voided Check Supporting Documents for Background Questions
Below you will find my contact information in case all documents have not been received as well as to return the forms: Agent Name: Phone Number: Email Address:
2 2 7 5 S W A L L O W H I L L R O A D , B U I L D I N G 3 0 0 , T H E B O U R S E , P I T T S B U R G H , P A 1 5 2 2 0
V O I C E ( 8 0 0 ) 5 6 2 - 7 7 3 3 F A X ( 4 1 2 ) 5 6 1 - 6 4 3 2 W W W . N E I S H L O S S . C O M
SureLC FAQ
Do I have to install software onto my computer to use SureLC? No, you do not have to install software to enjoy the benefits of SureLC. You can access SureLC through a web link on the Neishloss & Fleming, Inc. website.
How long does it take to set up my SureLC agent profile? You can be set up in SureLC and ready to submit contracting through SureLC in about 8 minutes.
Will I be required to complete a new agent profile each time I log into SureLC? No! After you complete your initial agent profile in SureLC, your information will be saved for the next time you want to contract for a carrier.
Can I select and submit contracting for multiple carriers at one time using SureLC? You will be able to submit multiple contracts while logged in to SureLC; however you cannot select multiple carrier contracts at one time because SureLC does ask additional questions based upon the carrier selected.
How do I electronically sign the contracting forms in SureLC? You have two options for loading your signature into the SureLC website.
The first option is to physically sign the Agent Signature document, scan it into your computer, and manually attach the document. The second option is to use your mouse to create an e-signature in the SureLC database. When completing the Agent Profile section of your profile, you will have the option to select the method you wish to use.
How do I get a copy of my voided check, E&O, and Signature Page into SureLC? You have a few options of uploading this information into the SureLC database. The first option is to scan and upload a copy of the documents and manually attach them to SureLC. The second option (which is a new feature to SureLC) is to use your computer’s webcam and take a picture of the documents. The webcam picture will automatically load the documents into the documents tab of SureLC.
If appointment fees are required for a carrier, am I able to pay them through SureLC via credit card? Unfortunately, if an appointment fee is required, you will need to send a check to Neishloss & Fleming, Inc. via USPS as SureLC is not set up to accept fee payment electronically. The fees can be mailed to:
Neishloss & Fleming, Inc. Attn: Administrative Division 2275 Swallow Hill Rd. Building 300 Pittsburgh, PA 15220
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AGENT'S CONTRACT
THIS CONTRACT, executed this the______day of ______________, 20_,
between NEISHLOSS & FLEMING, INC., of Pittsburgh, Pennsylvania, herein called
"N&F", and _______________________of ________________________,hereinafter called
the "AGENT", WHEREIN IT IS MUTUALLY AGREED AS FOLLOWS:
1. APPOINTMENT OF AGENT
N&F appoints the above named agent for the sale of certain applications for
policies of life and health insurance of Companies named in the attached
commission schedule. Agent is responsible for obtaining and maintaining proper
licensing with said Companies.
2. INDEPENDENT CONTRACTOR
Nothing contained herein shall be construed as creating the relationship of
employer and employee between N&F and the agent. The agent shall be free to
exercise his own judgement as to the time, place and manner in which he may
perform the services authorized under this agreement.
3. LIMITATIONS OF AUTHORITY AND DUTIES
The agent is not authorized and is expressly prohibited on behalf of N&F or
any Company named herein to incur any indebtedness or liability to make, modify,
discharge or waive any of the terms of any policy or contract, to extend the
time of any payments due or promise to pay a claim. N&F may from time to time
prescribe rules and regulations with respect to the conduct of the business
covered herein. The agent shall conform to and observe such rules and
regulations as established and amended by N&F.
4.COMPENSATION
As compensation in full for the performance of services, the agent, as
authorized in the contract, N&F will pay commissions as set forth in the
attached schedule of commissions. The rate of commissions may be changed,
altered or amended from time to time by N&F, and effective upon any business
written by the agent subsequent to the effective date of the change.
The Agent's commissions shall consist of the following:
(a) FIRST YEAR COMMISSIONS: Those percentages of the premium for the first
policy year as shown in the schedule of commissions.
(b) RENEWAL COMMISSIONS: Those percentages as shown in the schedule of
commissions.
(c) SERVICE FEE: A service fee shall be payable as shown in the schedule of
commissions if the agent is eligible. The agent shall be able to receive a
service fee only if at the time of payment of renewal premiums he (1) is
properly licensed and appointed by the Companies named in the schedule of
commissions, (2) is actively engaged with N&F as an agent, and (3) is servicing
all his business in a manner satisfactory to N&F. (4) Service fees will not be
paid after the death of the agent. (5) The agent maintains in-force annualized
individual plan premium of no less than fifty thousand dollars.
5. VESTED COMMISSIONS:
The vesting of commissions shall in no way limit or otherwise affect the
right of N&F or any Company to service the business on which vested commissions
are paid.
VESTED COMMISSIONS AFTER TERMINATION: this contract shall be terminated by the
death of the agent and all renewal commissions payable as provided herein shall
be vested and payable to the surviving spouse of the agent. If there is no
surviving spouse or is the spouse dies prior to receiving all renewal
commissions payable hereunder, then such renewal commissions shall be paid to
the Executors or Administrators of the agent's estate. If the contract should be
terminated by either party, or due to the death of the agent, personal
commissions will be payable as follows:
(a) The personal first year commissions on any policies in accordance with
the schedule of commissions will be vested and payable in accordance with said
schedule.
(b) The personal renewal commissions on any policies in accordance with the
schedule of commissions will be vested and payable in accordance with said
schedule, subject to: (1) No further commissions of any type will be payable
should any of the following conditions occur: (a) the agent commits or attempts
to commit any illegal, fraudulent or dishonest act; (b) the agent induces or
attempts to induce any policyholder in force with N&F and its Companies to
discontinue premium payments on any of their policies; (c) the agent induces or
attempts to induce any N&F agent, broker or employee to sever his relations
with N&F.
(c) If this contract is terminated for cause, as defined in the contract, no
further commissions, service fees or other compensation will be payable.
6. ASSIGNMENTS
No assignment of this contract or any compensation payable hereunder shall be
valid or binding on N&F unless authorized in advance by the President, a Vice
President, or Secretary. Any assignment so authorized shall be subject to any
and all indebtedness of the agent then existing or thereafter occurring.
7. VENUE STATED
Any suit between N&F and the agent growing out of any transaction arising
from, based on or in any way connected with this agreement shall be instituted
and tried only in Allegheny County, Pennsylvania. All of the terms, provisions
and conditions of this contract shall be construed according to the laws of
Pennsylvania.
8. INDEBTEDNESS
N&F shall have a first lien on all commissions payable under this agreement. For
purposes of this agreement, indebtedness shall include cash advances made by N&F
to the agent. The agent shall be responsible for and hereby agrees to the
repayment to N&F of such advances.
9. ACCOUNT STATED
The agent hereby agrees that the ledger accounts of N&F shall be competent and
sufficient prima facie evidence of the state of accounts between the parties
thereto. The failure of the agent to object in writing to specific items of the
statement of accounts furnished by N&F to the agent within sixty calendar days
from the date such statement of accounts is furnished, shall render such
accounts correct between the parties.
10. DEFINITIONS
Where the word "person" or the personal pronouns "he, him or his" are used in
this agreement, they are intended to be construed as both male and female, and
they are intended to mean the agent, whether the agent is an individual, a
partnership or corporation.
11. MODIFICATION
This agreement cannot be changed by any verbal promise or statement by any of
the parties thereto, and no written modification or change shall bind N&F unless
it is signed by the President, a Vice President or Secretary of the Company and
expresses an intention to modify or change this agreement.
12. NO WAIVER
No forbearance or neglect by N&F to enforce any term, condition or provision
of this contract shall be construed as a waiver of any of its rights hereunder.
13. TERMINATION
In the event the agent fails to comply with any of the provisions contained
herein, this contract may be immediately terminated by N&F by written notice to
the agent, such notice of termination to be effective on the date specified
therein. Forbearance or neglect on the part of N&F to insist upon the
performance of any part of this contract or to declare a forfeiture or
termination shall not be deemed to constitute a waiver of such rights and
privileges.
This contract shall terminate upon the death of the agent or upon his
becoming totally and permanently disabled. This contract may be terminated at
any time by either party desiring to terminate it giving the other party thirty
days written notice of termination, which notice shall be delivered either
personally or mailed to the last known address of the other party.
Upon termination of this contract, the agent shall immediately pay in cash to
N&F all sums then due.
IN WITNESS THEREOF, this contract is executed in duplicate this ________day of
________________, 20___, and when approved by an authorized officer of N&F,
shall be effective for all purposes as of the aforesaid date.
NEISHLOSS & FLEMING, INC.
______________________________ By__________________________
Agent's Name (Print) President or Secretary
______________________________ ___________________________
Agent Signature Agent S.S.#
2015 Highmark Medicare Advantage Commission
Agent
Please note: Highmark will forward compensation once the policy appears on the CMS report. Commission will not be paid prior to the policy effective date. Renewal amounts follow CMS’ designated compensation level from the year policy is written and are paid
annually on a calendar basis. Full charge back will occur if the member dis-enrolls less than 90 days after enrollment. Partial charge back will occur on a pro-rata monthly basis tying back to the effective date of the policy.
Medicare Advantage (Freedom Blue PPO & Security Blue HMO)
Initial Payment, new to MAYear 1
Renewal PaymentYears 2 - 10
$ 461 $ 230
Medicare Advantage (Community Blue HMO)
Initial Payment, new to MAYear 1
Renewal PaymentYears 2 - 10
$ 461 $ 230
Medicare Prescription Drug Plans (Blue Rx)
Initial Payment, new to MAYear 1
Renewal PaymentYears 2 - 10
$ 44.80 $ 22.40
MEDIGAP Blue
Applicant’sAttained Age
Initial PaymentYears 1-6
Renewal PaymentYears 7-10
Renewal PaymentYears 11+
under 65 & over80
$ 174.40paid monthly $ 14.53
$ 69.60paid monthly $ 5.80
$ 35.20paid monthly $ 2.93
65-79 $ 348.80paid monthly $ 29.07
$ 139.20paid monthly $ 11.60
$ 69.60paid monthly $ 5.80
Agent Signature: Date:
2275 Swallow Hill Road Building 300 The Bourse Pittsburgh, PA 15220 Phone 800.562.7733 Fax 412-561-3038 www.neishloss.com
Please use this form to designate commission payments from Neishloss & Fleming, Inc.
Agent Name: _______________________________________________________
Agency: ____________________________________________________________
Address:
___________________________________________________________________
___________________________________________________________________
City: _______________________________ State: __________ Zip: ____________
Tax ID: _____________________________________________________________
Comments/Instructions:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
2275 Swallow Hill Road Building 300 Pittsburgh, PA 15220
800-562-7733
[email protected] www.neishloss.com
Commission Direct Deposit Authorization
Instructions: Please complete Parts A through C, attach a voided check, and return to address above. Please Print.
Part A: Bank Account Holder Personal Information
Name / Payee:
Street Address:
City: State: Zip:
Phone Number: E-mail Address:
Part B: Bank Account Information
Action (please indicate):
□ Start Direct Deposit □ Change Account Information □ Stop Direct Deposit
Account Type (please indicate):
□ Checking □ Savings
Routing Number: □□□□□□□□□
Account Number: □□□□□□□□□□□□□□□□□□
Part C: Bank Account Holder(s) Signature(s)
I (we) give Neishloss & Fleming permission to automatically make commission payments to my (our) bank account. This authorization will remain in force unless I (we) cancel it or my (our) bank account is closed.
Signature: Date:
Joint Signature: Date:
Printed Name(s): /