Direct Benefits

AGENT APPOINTMENT CHECKLIST

APPOINTMENT PAPERWORK CONSISTS OF:

o Agent Personal History Record – Please complete and sign

o CS Background & NGL Questionnaire

o Signed Group Commission Schedule

o W-9 for Income Reporting – Complete and sign

o Independent Broker Agreement

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

o Citizens Security Life Ins. Co. Privacy Policy Addendum

o National Guardian Life Ins Co Agency Agreement (includes Hippa Rules and Tax Information)

o National Guardian Life Ins Co Business Associate Agreement

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

ALL THE ABOVE MUST BE SUBMITTED IN
ORDER TO BE APPOINTED

PLEASE RETURN ALL APPOINTMENT AND CONTRACTING INFORMATION TO:

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

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

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

Company of America, a/k/a The Guardian or Guardian Life.

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

For Office Use Only:
______________________________
______________________________

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


Social Security No.:		Birthdate:

Street:		Phone :

City:		State:	Zip Code:

Email:		Cell No.:	Fax No.:

BUSINESS
Name :		Tax ID :

Street :		Phone No. :

City:		State :	Zip Code :

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


In which states do you want to be appointed?


Please give previous employer (within last five years)

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

If Yes and you know your Agent#, please

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

AUTHORIZATION
Agent/ Broker Signature:			Date: 04 09 2010

AG - 8 REV 09/2010

GROUP AGENT
COMMISSION SCHEDULE

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

GROUP LIFE, DENTAL, AND VISION
EMPLOYER PAID OR VOLUNTARY

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

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

RENEWAL

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

1. Remains appointed with Citizens Security.

2. Remains licensed with the appropriate states DOI.

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


Accepted by:
	Agent/ General Agent

Date:04 09 2010
AG - 47

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

Name (as shown on your income tax return)

Business name, if different from above

Check appropriate box: Individual / Sole Proprietor Corporation Partnership Other

Exempt from backup withholding

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

City, state, and ZIP code

Requester's name and address (optional)

List account number(s) here (optional)

Part I

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

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

Social Security No

or

Employee Identification No

Part II

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

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

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

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


Sign Here	Signature of U.S person:	Date : 09 /04 /2010

Purpose of Form

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Part II. Certification

To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if items 1, 4, and 5 below indicate otherwise.

For a joint account, only the person whose TIN is shown in Part I should sign (when required). Exempt recipients, see Exempt From Backup Withholding on page 2.

Signature requirements. Complete the certification as indicated in 1 through 5 below.

1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification.
2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.
3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.
4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. ''Other payments include payments made in the course of the requester's trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.

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

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

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

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

Also see Special rules regarding partnerships on page 1.

Penalties

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

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

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

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

Specific Instructions Name

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

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

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

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

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

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

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

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

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

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

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

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

For this type of account:

Give name and SSN of:

1. Individual 2. Two or more individuals (joint account) 3. Custodian account of a minor (Uniform Gift to Minors Act) 4. a. The usual revocable savings trust (grantor is also trustee) b. So-called trust account that is not a legal or valid trust under state law 5. Sole proprietorship or single-owner LLC The individual The actual owner of the account or, if combined funds, the first individual on the account 1 The minor 2 The grantor-trustee 1 The actual owner 1 The owner 3 For this type of account:
Give name and EIN of: A valid trust, estate, or pension trust 6. Corporate or LLC electing corporate status on Form 8832 7. Association, club, religious, charitable, educational, or other tax-exempt organization 8. Partnership or multi-member LLC 9. A broker or registered nominee 10. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments 11. Sole proprietorship or single-owner LLC 12.

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

1. List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person's number must be furnished.

2 Circle the minor's name and furnish the minor's SSN.

3 You must show your individual name and you may also enter your business or ''DBA name on the second name line. You may use either your SSN or EIN (if you have one). If you are a sole proprietor, IRS encourages you to use your SSN. 4 List first and circle the name of the legal trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules regarding partnerships on page 1.

Note. If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S. possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.
You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.

INDEPENDENT BROKER AGREEMENT

Scanned license:

if you are unable to upload a copy, please fax a copy to 651-649-3502

Agent or Agency ("Broker"):

Social Security No. or Tax Identification No.:

Street Address:

Email Address:

Effective Date:

This Agreement is made by the above-named Broker (also "you," "your", or "yours") and Citizens Security Life Insurance Company, a Kentucky corporation (the "Company").

1. APPOINTMENT:

The Company appoints and authorizes you, as an independent contractor, to solicit the sale of and sell the Company's group insurance policies listed in the Company's Commission Schedule(s) provided to you (the "Policies") according to the terms hereof. No territory is assigned exclusively to you.

2. RESPONSIBILITIES:

a) You are authorized: (1) to collect initial premiums for the Policies made payable to the Company; and (2) to remit these initial premiums in full immediately to the Company or its designee without making any deductions therefrom. Premium must be only in the form of check, draft, or money order made payable to the Company. You should never accept cash or deposit an initial premium check, draft, or money order to your personal or business account

b) All premiums and any other funds due the Company which come into your possession are received in a fiduciary capacity only, and you will handle such premiums and other funds in accordance with law, and you will remit such premiums and other funds immediately to the Company.

c) You will: (1) promote the sale of the Policies according to the Company's underwriting guidelines which are communicated to you; (2) strive to achieve an underwriting profit on the Policies sold by you; (3) meet in a manner fully consistent with (1) and (2) of this Section 2(c) any sales quotas set for you by the Company.

d) You will conduct your business affairs in a highly responsible and reputable manner designed to further the interests of the Company.

e) While this Agreement is in effect, you will maintain errors and omissions insurance with limits of liability and deductible amounts, and issued by a carrier, acceptable to the Company.

f) The Company is not liable to you or to any other person for any expenses you incur or for damages of any kind or nature caused by you, and you will defend and protect the Company and its affiliates and hold the Company and its affiliates harmless against the claim or demand of any person for damages by reason of any willful or unauthorized or negligent act or omission of yours.

g) You shall not be liable to the Company nor any other person for any expenses the Company incurs or for damages of any kind or nature caused by an employee of the Company. The Company will indemnify and defend you against the claim or demand of any person for damages by reason of any willful or unauthorized or negligent act or omission of the Company or an employee of the Company.

3. LIMITS OF AUTHORITY:

a) If you desire to place advertising which names the Company, you must first receive the written approval of the Company or its designee.

b) You have no authority to modify or waive any term of any insurance application, Policy, or underwriting guideline or rate pertaining to a Policy.

c) You may not bind the Company on any type of contract other than the Policies, or do any other thing on behalf of the Company not expressly authorized herein.

4. PROCEDURE:

a) The Company or its designee will bill policyholders directly and will collect from policyholders all premiums subsequent to the initial premium paid in connection with any issued Policy, and all such premiums will be payable by the policyholder directly to the Company or its designee. You will strive to ensure that all premium payments made by policyholders, subsequent to the initial premium payment, are paid directly to the Company or its designee. You will service all Policies sold by or referred to you in a manner calculated to maintain friendly relations among policyholders, you, and the Company.

b) The acceptance, continuance, cancellation, and rejection of insurance coverages and payment of all claims rest exclusively with the Company or its designee. Should the Company or its designee for any reason refund any premiums on a Policy written by or referred to you, you will be liable for the repayment of any commissions received on such refunded premiums.

5. COMPENSATION:

a) As compensation for the sales and services you render hereunder where you are designated as the agent of record, you will be paid commissions for the Policies you sell and service, and which are paid for, according to the terms of the Company's Commission Schedules.

b) You agree to comply with all regulatory requirements related to the disclosure of broker or agent compensation.

c) The Company or its designee may: (1) upon 15 days' prior written notice to you, add new Policies to, or delete any Policy from, the Company's Commission Schedules; (2) without prior written notice to you, change any premiums for Policies to be sold thereafter; or (3) upon 15 days' prior written notice to you, change the commission payable on any Policy or modify the Company's Commission Schedules in any manner.

d) The Company or its designee may deduct from your commissions and other compensation the amount of any of your short remittances of premiums or other indebtedness to the Company, and if current commissions and other compensation due you are not sufficient to offset the amount of such short remittances or indebtedness, you will immediately remit such difference to the Company or its designee upon demand.

6. TERMINATION:

a) This Agreement may be terminated by the Company, its designee or you, without assigning cause, upon 30 days' prior written notice delivered personally or sent by overnight courier or certified mail with postage fully prepaid to the other party at the addresses shown in this Agreement, and may be terminated by the Company or its designee, for cause, at any time upon written notice to you. As used in the preceding sentence, "for cause" includes, but is not limited to, a single instance of: (1) mishandling or misappropriation of premium by you or an employee or agent of yours; (2) failure to follow the Company's underwriting guidelines communicated to you; (3) your violation of any term of this Agreement; or (4) your violation of any applicable statute, regulation, or other law.

b) Upon termination of this Agreement, you will remove immediately from your place of business, at your expense, all signs relating to the Company, and you will cease to hold yourself out to anyone as the Company's agent.

c) Upon termination of this Agreement, you will be entitled only to commissions which are then unconditionally due and payable, less the amount of any and all obligations of yours due or to become due the Company, including, but not limited to: (1) premiums; (2) commission returns on terminated Policies; (3) the replacement cost of unreturned or damaged signs, manuals, rate books, and supplies; (4) the cost of reconstructing undelivered or incomplete flies and records necessary to service the Company's insureds or insurance business; and (5) all of the other costs of the Company or its designee resulting from your failure to comply with the terms of this Agreement. Any amount you are entitled to hereunder upon termination of this Agreement will be paid to you as soon as practicable after such termination.

d) Upon written notice of the termination of this Agreement, the Company or its designee will be entitled to immediate possession of, and, upon the Company's or its designee's request, you will deliver to the Company all files and records necessary to service the Policies, and the Company or its designee will, after such delivery, be responsible for the servicing of such insureds and insurance business. Upon termination of this Agreement, the Company or its designee will be entitled to immediate possession of, and within 24 hours after such termination, you will deliver to the Company or its designee: (1) any and all files and records necessary to service the Company's insureds or insurance business which were not previously returned to the Company or its designee; (2) all material bearing the name or insignia of the Company, including all signs, manuals, rate books, forms, sales aids, stationery, envelopes, applications, and Policies; and (3) any and all other material or property furnished by or owned by the Company or necessary to service the Company's insureds or insurance business.

7. GENERAL PROVISIONS:

a) You are an independent contractor, not an employee. You agree that because you are engaged in your own independent business, you will not participate in any pension or retirement (including, but not limited to, annuity) benefits or be eligible for unemployment compensation benefits or workers compensation benefits from or through the Company. You will: (1) Exercise your own judgment with respect to, and be responsible for, controlling the manner of your performance hereunder; (2) Be responsible for scheduling and controlling the number of hours to be worked; (3) Be responsible for providing your place of business and business equipment, at your expense; (4) Be compensated for services performed hereunder only in direct relation to sales produced and in accordance with the current applicable company commission schedules; (5) Secure an employer identification number, if necessary, and maintain detailed records of income and expense with respect to the services performed hereunder adequate to prepare federal and state income tax returns: and (6) Timely file all tax returns and reports required of self-employed independent contractors by federal, state, and local government authorities. You acknowledge that neither the Company nor its designee will withhold any taxes from your earnings, or pay any taxes on your behalf, and that you are solely responsible for the payment of all taxes directly or indirectly related to the payment of compensation for your services hereunder. You will secure and maintain in force your own Workers' Compensation coverage (or similar coverage, if not qualified therefore) and public liability insurance coverage with limits of liability acceptable to the Company, and you will provide certificates of such coverages to the Company upon request. Such certificates will provide, among other things, that no such coverage may be modified or terminated without at least 10 days' prior written notice to the Company.

c) The Company or its designee may during ordinary business hours inspect, audit, and copy any or all of your files, books, accounts, and records relating to the Company’s insureds or insurance business.

d) Except as provided in Sections 5(c) and 6(a) of this Agreement, this Agreement may be amended only in a written instrument signed by the parties.

e) This Agreement shall be binding upon the parties, their successors, and permitted assigns. Neither party shall assign its rights, duties, or obligations hereunder without obtaining the consent of the other party, except that the Company may assign its rights, duties, and obligations hereunder to another insurance company designated by the Company. By entering into this Agreement, you agree to such assignment by the Company to an insurance company designated by the Company without any further action or obligation on the part of the Company.

f) If any term of this Agreement violates any applicable statute, regulation, or other law in your territory, that term is hereby automatically amended to conform to the minimum relevant requirements, if any, provided under such statute, regulation, or other law.

g) Failure of the Company to insist upon compliance with any of the terms of this Agreement or with any of the instructions or the underwriting guidelines communicated to you will not be construed as a waiver thereof unless the Company or its designee in each instance so provides in writing, but all of the same will continue in full force and effect. You understand and agree that the Company and its designee reserves the right to be inconsistent in administering broker agreements from one person to another, and you hereby waive any and all claims based upon or arising out of any such inconsistency.

h) You acknowledge having read and understood this Agreement in its entirety and having had an opportunity to consult with legal or other counsel regarding this Agreement prior to signing the same.

i) Any right of the Company regarding any of your duties hereunder may be enforced in any appropriate manner including, but not limited to, injunctive or other equitable relief when the circumstances justify the same.

8. SIGNATURES:

IN WITNESS WHEREOF, you and, by their authorized representatives, the Company have executed this Agreement effective as of the day and year first written above.

BROKER	CITIZENS SECURITY LIFE INSURANCE CO.

By:	By:

Title:	Title:

( Signature )	( Signature )

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

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

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

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

Sincerely,

Jim Knox
Sr. Vice President, Group Benefits

New
Change
No Thanks

ELECTRONIC FUNDS TRANSFER AUTHORIZATION

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

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

provisions of U.S. law.

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

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


Signature of Depositor	Date 09/04/2010	Signature of Depositor (if joint account)	Date 09/04/2010

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

Name of Bank

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

ADDENDUM

Citizens Security Life Insurance Company
Privacy Policy

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

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

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

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

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

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

Signature of Depositor

Sr. Vice President, Group Benefits

National Guardian Life Insurance Company Agency Agreement
MADISON, WISCONSIN
("the Company" or "Us" or "Our")
HEREBY APPOINTS



Authorized Representative ("You" or "Your")	Name of Agency ("You" or "Your")	City and State

IT IS AGREED AS FOLLOWS:

1. You are authorized to solicit and procure applications for such policies described in the most recent schedules then in effect as may be issued by the Company and collect the full initial premiums thereon. All such premiums shall be paid promptly to the Company not subject to any offset by You and not to be commingled with Your personal or Agency funds.

2. You have no authority to make, alter or discharge any policy agreement, or extend the time of payment of any premium; or waive any policy condition; or guarantee any dividend; or deliver any policy unless the insured is at that time in good health and insurable condition; or endorse checks payable to the Company; or collect any premium except the initial premium on policies issued hereunder.

3. You agree to conduct yourself in accordance with the rules, instructions and regulations of the Company and the insurance laws and regulations of the state in which You solicit applications for the Company. If Your license is suspended, revoked or not renewed by any state, Your right to solicit business on our be half in that state will be suspended until such time as Your license is reinstated or renewed.

4. From the Company's and Your standpoint, You are an independent contractor. Nothing contained in this agreement or in any course of dealing between the Writing Agent and the Company whether in the past or currently shall be construed or interpreted to create an employer-employee relationship between the Company and the Agency. You have no obligation hereunder to solicit applications for the Company, and You are free to exercise Your own judgment as to the persons from whom applications are solicited, and the companies with which You will place such insurance. The Company shall bear none of the expenses of conducting Your business under this appointment.

5. Compensation.The commissions provided for herein, which are subject to change at any time upon written notice to You as to policies bearing Effective Dates subsequent to such notice, shall be payable to You, Your executors, administrators or assigns, except that no assignment of commissions accrued or to accrue shall be binding upon the Company without its written consent. If this Agreement terminates because of the dissolution of the Agency, no commissions shall be payable hereunder subsequent to the date of dissolution.

Commissions are not paid or due on individual and group conversion plans, and on policies or contracts issued to a policy owner or contract owner within six (6) months before or after termination of another policy or contract of the Company issued to such policy owner or contract owner, to the extent not otherwise provided for herein.

Commissions payable with respect to the same policy or contract may be divided between the Agency and other Agents licensed with the Company. In such case, earned payments for such policy or contract shall be allocated among Agents proportionately by the Company for commission payment purposes only.

Commissions paid by the Third Party Administrator to You shall constitute full compensation for Your services performed in accordance with this Agreement. You are responsible for all expenses incurred by You in performance of this the Company and the employer or group is terminated for any reason, the fee payable to You will be adjusted to reflect same.

You shall be entitled to a commission for so long as You remain the broker of record and this agreement is in force. If an employer or group solicited by You provides us with notification of a change of its broker of record, Your entitlement to fees with respect to such employer or group shall terminate at the close of business on the effective date of the change designating another broker of record.

At any time while this agreement is in effect, or after it is terminated, the Agency shall forfeit and shall not be entitled to receive any commissions or service fees due or to become due under this agreement, if the Agency shall:

a. Violate any of the provisions of this agreement, or

b. Shall neglect to report and pay over to the Company any premium collected by the Agency, or sub-producer(s), or

c. Shall endeavor to induce or shall induce any employee, producer or representative of the Company to discontinue their association with the Company.

If the Company shall return the premiums on a policy or any portion of such premiums or cancel a policy for any cause, You shall refund to the Company on demand the amount of commissions received on the premiums so returned. This provision shall survive termination of this agreement.

If a policy issued hereunder should be lapsed for more than ninety days and subsequently be reinstated, the Company shall be relieved of any further commission liability to You unless the reinstatement application for such policy was procured by you.

6. Assignment. You agree to assign all right, title and interest in all commission income due and payable under this Agreement to the Third Party Administrator (TPA) contracted with the Company to administer commissions to you related to business written by you under this Agreement. You further direct the Company to report to the TPA all commission income hereby assigned, and acknowledge that the Company has made no representations as to the tax treatment of such assigned commissions.

This assignmen is subject to the right to offset against any such commission payable any indebtedness of you to the Company existing or hereafter incurred. This assignment shall continue in effect until such time as no further commissions are due and payable to you from the Company on the subject business, or until the Company c/o the TPA receives written notice that this assignment has been terminated.

7. Underwriting. The Company reserves the right at its sole option to decline any application for coverage, to refuse to renew any coverage, to withdraw any policy or contract form, or to return directly to covered persons or applicants any payments submitted to the Company without liability to the Agency. This provision survives termination of this agreement.

8. Indebtedness. 1. Any advance, loan, or extension of credit which the Agency at any time and in any manner may secure from the Company shall constitute an indebtedness to the Company. If any check or draft of the Agency used to transfer monies to the Company is dishonored upon presentation for payment, the amount thereof shall constitute an indebtedness of the Agency to the Company.

2. Provisions Relating to Indebtedness.

a. The entire indebtedness to the Company of the Agency, as recorded in the records of the Company, may be deemed due and payable in full by the Company at any time.

b. The Agency shall be responsible for any costs, including reasonable attorney fees and other collection expenses, incurred by the Company in connection with the recovery from the Agency of any indebtedness of the Agency to the Company.

c. The Agency hereby grants to the Company a first security interest in all commissions becoming due hereunder to secure any indebtedness of the Agency to the Company; and the Company may at any time apply commissions payable to the Agency hereunder or any other monies payable to the Agency by the Company or by any company controlled by or under common contract with the Company to reduce any such outstanding indebtedness.

8. Advertising. You have no authority to advertise using the Company name, products, premium rates, or other related information unless the advertisement is pre-approved in writing through the Company’s advertising review process.

9. Privacy. You agree that all nonpublic personal financial information or nonpublic personal health information related to any insured or policyholder or to any consumer or customer (as such terms are defined under applicable state or federal privacy laws) of Us or any of Our affiliated companies, obtained by You in the performance of Your duties and obligations under this Agreement shall be held in the strictest confidence by You, Your producers and Employees. You shall not disclose or use such information except as necessary to carry out Your duties and obligations under this Agreement or as otherwise required under applicable state or federal law. This provision survives termination of this Agreement.

10. Termination. In addition to the methods otherwise herein provided, this agreement may be terminated by either party hereto, by notice in writing of the election to terminate delivered personally or mailed certified to the other party at the last known address. Said termination shall be effective ten calendar days after the date shown on such termination notice or as state regulation dictates. After the termination date, commissions which would otherwise be subsequently earned shall no longer be due. Upon the death of the Agent, this agreement shall terminate and any monies which are then earned and to which the Agent would have been entitled at the time of his death or dissolution of Agency shall be paid, as the premiums are paid to the Company on behalf of the Agent, to whomsoever shall be entitled thereto by the laws of descent and distribution, or the last will and testament of the Agency. Such monies will be held by the Company without interest or penalty until lawful determination is accepted by the Company as to the recipient of the monies.

11. Term for Cause. This agreement shall be terminated for cause immediately by written notice to the other party.

12. Territory. The territory in which You are licensed to represent us is not exclusively assigned to You and we have the right to enter into similar arrangements with others and You have the same right.

13. Audit of Agency. All books, accounts and records of the Agency related to the business of the Company shall be subject to audit and inspection by the Company or its duly authorized representative at all times, including a period of sixty (60) days after termination hereof. The Company may at any time make copies of or take extracts from such books, accounts, paper documents and records as it may deem necessary.

14. Re cords and Supplies.We shall have the right, but not the obligation, at all reasonable times to inspect Your papers, documents and records, wherever located, which relate to Our business. All records maintained by the Agency hereunder and all books, rate manuals, forms and other supplies furnished to the Agency by the Company shall be and remain the property of the Company and shall be returned to the Company promptly following termination hereof. All notices shall be deemed given when received.

15. Legal Proceedings. The parties hereto consent, to the extent permitted by law, that jurisdiction and venue for the enforcement or interpretation of this agreement is Madison, Wisconsin. The parties herewith further agree that the law of the State of Wisconsin shall apply to enforcement, construction, and interpretation of this agreement. Any document that has been served upon You in connection with any legal proceedings involving us must be transmitted to the Home Office by registered mail within 24 hours after receipt. You will be liable to us for any loss or expense we incur resulting from Your failure to comply with this requirement. You hereby represent, and agree that this Agreement is contingent on Your continuing representation, that You have not been convicted, and to the best of Your knowledge that none of Your producers or employees have ever been convicted, of any state or federal felony involving dishonesty or a breach of trust or any crime under 18 U.S.C. § 1033. You agree to notify us immediately in writing of any charges or actions brought in any court or by any regulatory body against You, Your producers or employees and of any felony conviction(s) of You, Your producers or employees. Failure to comply with any of the provisions of this section shall be cause for immediate termination of this Agreement. If a dispute arises out of or relates to this agreement, or breach thereof, which cannot be settled through discussion or negotiation, The Company and You agree to use binding arbitration according to the rules of the American Arbitration Association as the only method to resolve disagreements or claims that are cognizable in a court of law.

16. Prior Contracts Superseded.This Agreement shall supersede any and all prior Contracts between the parties hereto, whether written or oral, regarding the services of the Agency performed for the Company with respect to such products. This Agreement and its attachments constitute the entire agreement between the parties hereto and is subject to termination by either party upon written notice to the other party. All previous agreements are void and replaced by this agreement.

17. Additional Provisions. Our failure to insist upon strict performance of any provisions in this Agreement will not be construed as a waiver of such provisions. This Agreement is not binding on You unless signed by You and is not binding on Us unless signed by one of Our authorized officers.

18. Hold Harmless. Each party to this Agreement will indemnify, defend and hold harmless the other party from and against any and all claims, losses, and expenses, including without limitation reasonable attorney’s fees and costs of defense, that such other party incurs as a result of the first party’s error, faulty action or omission or breach of the Agreement.

19. Subject to approval by the Company, this Agreement shall take effect on the day of , .

I accept this appointment subject to the terms and conditions herein provided.

Agency Name

Authorized Representative’s Signature

Social Security No. DOB

HIPAA RULES, REGULATIONS & GUIDELINES - Agency

As agreed by both parties, the current federal guidelines as stated by the U.S. Department of Health and Human Services and outlined within the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) regulations, allow for the assignment and recognition of a “Business Associate” relationship between two organizations, whereas one of the organizations is able to perform certain functions and services for the other organization, as required by federal and state regulations, so as to facilitate compliance with said regulations.

Agency agrees to perform said functions and services stated in the Agency Agreement between the parties for National Guardian Life Insurance Company so as to enable National Guardian Life Insurance Company to comply with the Federal Government regulations promulgated under HIPAA, specifically pertaining to data collection and transfer of data between both parties as well as Agency and third-party entities, on the behalf of National Guardian Life Insurance Company and National Guardian’s Participating Providers using the specific mandated data content and format as required by the U.S. Department of Health and Human Services and the HIPAA regulations governing Standard’s for Electronic Transactions, Privacy and Security. If either party should violate such rules, regulations or guidelines (with or without knowledge), the violating party with written notice by the non-violating party, shall have reasonable time to cure such violation from time of knowledge or notice. If the violating party does not cure the violation within a reasonable time, the non-violating party may terminate the agreement with written notice indicating that the violating party has not cured the violation in a reasonable time and has not presented a good faith effort to cure such violation.

Should either state, federal and/or other regulatory governing bodies change existing guidelines during the Term so as to negate the relationship between Agency and National Guardian Life Insurance Company, or cause the said understanding of the relationship by both parties to become invalid, both parties shall work in good faith to re-address and re-define their existing relationship so as to become compliant under the new regulations and/or mandates in an expedient and timely manner.

WITNESS the hands of the undersigned this day of , .

I accept this appointment subject to the terms and conditions herein provided.

Agency Name

Authorized Representative’s Signature

Fair Credit Reporting Act Consumer Disclosure – Authorized Representative and Agency:

Obtaining a “Consumer Report” NGL1, when making a decision to offer you a producer Agreement or to continue an Agreement may obtain and use a “consumer report” from a “consumer reporting agency.” These terms are defined in the Fair Credit Reporting Act as amended, 15, U.S.C. § 1681 et seq. (“FCRA”).

A “consumer reporting agency” is defined in the FCRA as a person or business that for monetary fees, dues, or in a cooperative nonprofit basis, regularly engages in whole or in part in the practice of assembling or evaluating consumer credit information or other information on consumers for the purpose of furnishing consumer reports to others.

A “consumer report” is defined by the FCRA as including any written, oral or other communication of any information by a “consumer reporting agency” bearing on a consumer’s credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living, which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in employment –related-decisions affecting a consumer.

As an Agency with an interest in a relationship as a producer with NGL, you are a “consumer” with rights under the FCRA. If NGL obtains a “consumer report” about you and if NGL considers any information in the consumer report when making a decision that adversely affects you, you will be provided with a copy of the “consumer report” before the decision becomes final. You may also contact the Federal Trade Commission about your rights under the FCRA.

Signature of Authorized Representative: Date:09/04/2010 1 For purposes of this Authorization and Release, NGL includes National Guardian Life Insurance Company, its related companies and their agents.

National Guardian Life Insurance Company c/o

Company Name:

Address:

City/ST/Zip

Phone:

TAX INFORMATION

The Internal Revenue Service has notified us that the Tax I.D./Social Security Number AND name under which you are contracted with National Guardian Life Insurance Company must be an identical match. Please complete and sign the Taxpayer Identification Number form below.

REQUEST FOR TAXPAYER IDENTIFICATION NUMBER

Agent / Agency

Address

City, State, and ZIP Code

TAXPAYER IDENTIFICATION NUMBER
Enter your taxpayer identification number
(employer identification number) in the
appropriate box.

Employer Identification Number

CERTIFICATION. Under penalties of perjury, I certify that:

The number shown on this form is the Agency’s correct taxpayer identification number.

Signature Date09/04/2010
(Authorized Representative)

BUSINESS ASSOCIATE AGREEMENT

This Business Associate Agreement (the “ Agreement ”) effective as of (“ Effective Date ”), is entered into by and between National Guardian Life Insurance Company and (“ Covered Entity ”) and (“ Business Associate ”) (collectively, “the Parties ”).

RECITALS

WHEREAS , the purpose of this Agreement is to comply with the requirements of the Health Insurance Portability and Accountability Act of 1996, as heretofore or hereafter amended (" HIPAA "), and associated regulations 45 C.F.R. parts 160 - 164, as heretofore or hereafter amended (the " Privacy and Security Rules ")

WHEREAS , the Parties have heretofore entered into, or may hereafter enter into, one or more agreements or arrangements whereby Business Associate shall or may provide certain services to Covered Entity, and pursuant to such agreements or arrangement(s), Business Associate may be considered a "business associate" of Covered Entity as defined in the Privacy and Security Rules; and

WHEREAS , Business Associate may have access to Protected Health Information (as defined below) in fulfilling its responsibilities under such agreements or arrangement(s);

NOW, THEREFORE , in consideration of the Parties continuing obligations under this Agreement, compliance with HIPAA and the Privacy Security Rules, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the Parties agree to the provisions of this Agreement in order to address the requirements of the Privacy and Security Rules and to protect the interests of both Parties.

SECTION 1. INTERPRETATION; DEFINITIONS

1.1 Interpretation. In the event of an inconsistency between the provisions of this Agreement and the provisions of the Privacy and Security Rules, the Privacy and Security Rules shall control. Where provisions of this Agreement are different than those mandated by the Privacy and Security Rules, but are nonetheless permitted by the Privacy and Security Rules, the provisions of this Agreement shall control. Any ambiguity in this Agreement shall be resolved to permit Covered Entity to comply with the Privacy and Security Rules.

1.2 Definitions . Any and all capitalized terms in this Agreement shall have the definitions ascribed to them herein. Whenever the context so requires, the gender of all words used in this Agreement includes the masculine, feminine, and neuter, and the singular shall include the plural, and conversely.

1.2.1 Electronic Protected Health Information (EPHI)means individually identifiable health information that is Transmitted by electronic media, maintained in electronic media; or transmitted or maintained in any other form or medium.

1.2.2 Electronic Storage Media is defined as memory devices in computers (hard drives) and any removable/transportable digital memory medium such as magnetic tape or disk, optical disk, or digital memory card;

1.2.3 Individual shall have the same meaning as the term "Individual" in 45 CFR §164.501, as amended, and shall include a person who qualifies as a personal representative in accordance with 45 CFR §164.502(g).

1.2.4 Protected Health Information shall have the same meaning as the term "Protected Health Information" in 45 CFR §164.501, as amended, limited to the information provided by Covered Entity to Business Associate, or created or received by Business Associate on behalf of Covered Entity.

1.2.5 Required By Law shall have the same meaning as the term "Required By Law" in 45 CFR §164.501, as amended.
1.2.6 Secretary shall mean the Secretary of the United States Department of Health and Human Services or his/her designee.

1.2.7 Transmission Media shall mean media used to exchange information already in electronic storage media. Transmission media include, for example, the internet (wide-open), extranet (using internet technology to link a business with information accessible only to collaborating parties), leased lines, dial-up lines, private networks, and the physical movement of removable/transportable electronic storage media.

SECTION 2.SERVICES

Pursuant to its current or future agreement(s) or arrangement(s) with Covered Entity, Business Associate shall or may provide services which may involve the use and/or disclosure of Protected Health Information. Except as otherwise specified herein, Business Associate may make any and all uses of Protected Health Information necessary to perform its obligations under its arrangement(s) and agreement(s) with Covered Entity.

SECTION 3. RESPONSIBILITIES OF BUSINESS ASSOCIATE

3.1 Responsibilities of Business Associate. With regard to its use and/or disclosure of Protected Health Information, the Business Associate hereby agrees to the following:

3.1.1 Not to use or disclose Protected Health Information except as permitted or required by this Agreement or as Required By Law;

3.1.2 To use appropriate safeguards to maintain the security of the Protected Health Information and to prevent unauthorized use and/or disclosure of the Protected Health Information;

3.1.3 To report to the designated privacy officer of Covered Entity, in writing, any use and/or disclosure of the Protected Health Information that is not permitted, required by this Agreement, or Required By Law, of which Business Associate becomes aware within ten (10) days of Business Associate’s discovery of such unauthorized use and/or disclosure;

3.1.4 To mitigate, to the extent practicable, any harmful effect that is known to Business Associate of a use or disclosure of the Protected Health Information by Business Associate in violation of this Agreement;

3.1.5 To require all of its employees, representatives, subcontractors, and agents that receive or have access to the Protected Health Information under this Agreement to agree in writing to adhere to the same restrictions and conditions on the use and/or disclosure of the Protected Health Information that apply herein;

3.1.6 Upon written request, to make available during normal business hours at Business Associate’s offices, within ten (10) calendar days of such request, all books, records, and agreements, including policies and procedures, relating to the use and disclosure of the Protected Health Information to Covered Entity for purposes of enabling Covered Entity to determine Business Associate’s compliance with the terms of this Agreement;

3.1.7 Upon written request, to make available all books, records, and agreements, including policies and procedures, relating to the use and disclosure of the Protected Health Information to the Secretary in a time and manner designated by the Secretary;

3.1.8 To document any disclosures of the Protected Health Information and information related to such disclosures as would be required for Covered Entity to respond to a request by an Individual for an accounting of disclosures of the Protected Health Information in accordance with 45 CFR §164.528; and

3.1.9 To provide to Covered Entity or an Individual, in the time and manner designated by Covered Entity, information collected in accordance with this Agreement to permit Covered Entity to respond to a request by an Individual for an accounting of disclosures of the Protected Health Information in accordance with 45 CFR §164.528.

3.2 Responsibilities of Business Associate. With regard to its use and/or disclosure of Electronic Protected Health Information (EPHI), the Business Associate hereby agrees to the following:

3.2.1 Implement each “Required” administrative, physical, and technical safeguard that reasonably and appropriately protects the confidentiality, integrity, and availability of the electronic protected health information that it creates, receives, maintains, or transmits on behalf of the covered entity as required by the security regulations 45 CFR 164.302 through 45 CFR 164.318 or as later amended;

3.2.2 Ensure that any agent, including a subcontractor, to whom the administrator provides EPHI, agrees to implement reasonable and appropriate safeguards to protect such EPHI;

3.2.3 Report to Covered entity in writing any EPHI that the Business Associate creates, receives, maintains or transmits on behalf of NGL that is not permitted or required by the Agreement within 15 days of the Administrator’s discovery;

3.2.4 For each standard that is “Addressable” the Administrator must either implement the specification or document why implementing the specification is not reasonable and implement an equivalent alternative measure.

SECTION 4.OBLIGATIONS OF COVERED ENTITY

4.1 Obligations of Covered Entity. With regard to the use and/or disclosure of the Protected Health Information by Business Associate, Covered Entity hereby agrees to the following:

4.1.1 To notify Business Associate of any changes in the form of notice of privacy practices that Covered Entity provides to Individuals pursuant to 45 C.F.R. §164.520 and to provide Business Associate with a copy of the notice currently in use;

4.1.2 To notify Business Associate of any changes, restrictions, or revocation of, permission by Individuals to use or disclose the Protected Health Information, to the extent that such changes may affect Business Associate's use or disclosure of the Protected Health Information; and

4.1.3 Not to request Business Associate to use or disclose the Protected Health Information in any manner that would not be permissible under the Privacy and Security Rules if done by Covered Entity.

SECTION 5.TERM AND TERMINATION

5.1 Term. The term of this Agreement shall commence as of the Effective Date and shall continue until all of the Protected Health Information provided by Covered Entity to Business Associate, or created or received by Business Associate on behalf of Covered Entity, is destroyed or returned to Covered Entity, or, if it is unfeasible for Business Associate to return or destroy the Protected Health Information, protections are extended to such information by Business Associate, in accordance with the termination provisions of this Agreement.

5.2 Termination for By Covered Entity. Upon a material breach by Business Associate of any of its obligations hereunder, it shall immediately provide notice thereof to Covered Entity, and Covered Entity shall:

5.2.1 Provide an opportunity for Business Associate to cure the breach or end the violation within a time period which Covered Entity determines is reasonable under the circumstances, terminate this Agreement if Business Associate does not cure the breach or end the violation within the time specified by Covered Entity; or

5.2.2 Immediately terminate this Agreement if Business Associate has breached a material term of this Agreement and a cure by Business Associate of such breach is not possible; or

5.2.3 If neither termination nor cure are feasible, Covered Entity shall report the violation to the Secretary.

5.3 Termination by Business Associate. If Business Associate determines that a material condition of performance has changed under this Agreement, or that Covered Entity has violated the terms of this Agreement, Business Associate may provide thirty (30) days prior written notice to Covered Entity of its intention to terminate this Agreement. Business Associate agrees to cooperate with Covered Entity to reach a mutually satisfactory solution to the matter prior to terminating this Agreement and this Agreement shall terminate only if such a solution is not reached.

5.4 Effect of Termination. 5.4.1 Except as provided in Section 5.4.2, upon termination of this Agreement for any reason, Business Associate shall promptly return or destroy all the Protected Health Information received from Covered Entity, or created or received by Business Associate on behalf of Covered Entity. This provision shall apply to the Protected Health Information that is in the possession or under the control of subcontractors or agents of Business Associate. Neither Business Associate, nor its subcontractors or agents, shall retain copies of the Protected Health Information; or

5.4.2In the event that the return or destruction of the Protected Health Information is unfeasible, Business Associate shall promptly provide to Covered Entity notification of the conditions that, in its view, make return or destruction unfeasible. Subject to Covered Entities' agreement therewith, Business Associate shall extend the protections of this Agreement to such Protected Health Information and limit further uses and disclosures of such Protected Health Information to those purposes that make the return or destruction unfeasible, for so long as Business Associate, its subcontractors or agents, maintain such Protected Health Information. All obligations of Business Associate under Section 3 shall continue as long as such Protected Health Information is maintained by Business Associate and its subcontractors or agents.

5.4.3 Business Associate's obligations under this Section 5.4 shall survive the termination of this Agreement indefinitely.

5.4.4 Should this Agreement be terminated for cause by Covered Entity, such termination shall be considered a material default by Business Associate under any underlying agreement between it and Covered Entity and shall entitle Covered Entity to terminate that agreement.

SECTION 6. MISCELLANEOUS

6.1 No Third Party Beneficiaries . Nothing express or implied in this Agreement is intended to confer, nor anything herein shall confer, upon any person other than the Parties hereto any rights, remedies, obligations, or liabilities whatsoever.

6.2 Amendment . This Agreement may not be modified or amended, except in writing signed by each Party. The Parties agree to take such action as is necessary to amend this Agreement from time to time as is necessary for Covered Entity to comply with the requirements of HIPAA and the Privacy and Security Rules.

6.3 Survival . The respective rights and obligations of Business Associate under this Agreement shall survive the termination of this Agreement.

6.4 Assistance in Litigation or Administrative Proceedings . Business Associate shall make itself, and any employees, subcontractors, or agents assisting Business Associate in the performance of its obligations under this Agreement and those agreements and arrangements described in Section 2, available to Covered Entity, at no cost to Covered Entity, to testify, be deposed, or otherwise assist Covered Entity and its counsel in the event of litigation or administrative proceedings commenced against Covered Entity, its officers, directors, and employees, based upon a claimed violation of HIPAA, the Privacy and Security Rules, or other laws relating to security and/or privacy, except where Business Associate or its employee, subcontractor, or agent is named as an adverse party in the proceeding. The provisions of this Section shall survive the termination of this Agreement indefinitely.

6.5 Indemnification . Business Associate agrees to indemnify Covered Entity, its assignees and licensees, and hold each of them harmless from and against any and all claims, demands, losses, damages, liabilities, costs, and expenses, including legal fees, arising out of or by reason of any breach or alleged breach by Business Associate, its employees, subcontractors, or agents, of any of its obligations under this Agreement.

6.6 Notices . All notices required under this Agreement shall be deemed to have been properly served if delivered in writing personally, by recognized overnight delivery services (such as Federal Express), by facsimile (confirmed by telephone), or by U.S. registered or certified mail, postage prepaid, return receipt requested, addressed as follows:

If to Covered Entity:

National Guardian Life Insurance Company

Two East Gilman Street

P.O. Box 1191

Madison, Wisconsin 53701-1191

Attention: President

Telephone: 608.257.5611

Fax: 608.257.4282

And to

Telephone:

Fax:

If to Business Associate:

Telephone:

Fax:

or such other place or places as either Party, by notice given in accordance with this Section, may designate in writing from time to time. All notices shall be effective upon receipt by the Party to be notified.

6.7 Governing Law. This Agreement shall be governed under the laws of the State of Wisconsin.

6.8 Recitals. The RECITALS set forth hereinabove are incorporated herein in their entirety.

6.9 Counterpart Execution. This Agreement may be executed in any number of counterparts, each of which shall be an original, but all of which shall together constitute one and the same instrument. For purposes hereof, facsimile copies hereof and facsimile signatures hereof shall be authorized and deemed effective.

6.10 Entire Agreement. This Agreement sets forth the entire agreement of the Parties hereto with respect to the subject matter hereof and supercedes all prior discussions and agreements, written or oral, with respect thereto.

IN WITNESS WHEREOF, the Parties have executed this Agreement as of the day and year written above.

“COVERED ENTITY”

NATIONAL GUARDIAN LIFE

INSURANCE COMPANY

By:

Name: Timothy J. Nicholson

Title: Vice President & CMO

“ Company Name ”:

By:

Name:

Title:

“BUSINESS ASSOCIATE” NATIONAL GUARDIAN LIFE INSURANCE COMPANY

By:

Name:

Title:

NAME OF AUTHORIZED REPRESENTATIVE		EMAIL ADDRESS		DATE 09 04 2010

NAME OF CORPORATION AGENCY

BUSINESS ADDRESS	CITY	STATE	ZIP CODE	PHONE


MAILING ADDRESS (P.O. Box) if different from above	CITY	STATE	ZIP CODE	FAX #


CONTACT NAME		EMAIL ADDRESS		PHONE

Background : (Please explain, including dates, and "yes" answers on a separate sheet) Has Authorized Representative / Agency ever :

been appointed by National Guardian Life Insurance Company?	YES NO

had a complaint filed against you with an Insurance Department? State?	YES NO

been refused abond?	YES NO

been the subject of any investigationor proceeding by any insurance jurisdiction?	YES NO

had any agency contract or compny appointment canceled for cause (e.g., misrepresentation, misappropriation, etc.)	YES NO

been suspended, expelled,fined,barred, censured, or otherwise disciplines or found to have violated any law or rule by any party in the insurance industry?	YES NO

been refused a license to sell insurance or membership in any insurance oragnization or had a license suspended or revoked for cause by any jurisdiction?	YES NO

withdrawn any application or surrendered any license to avoid	YES NO

been convicted of or pleaded no contest to any felony or misdemeanor, except for traffic offenses?	YES NO

have any criminal charges pending against you?	YES NO

gone through bankruptcy, had salary attached or had any liens or judgements outstanding against you?	YES NO

been named a party in any lawsuit?	YES NO

Are you presently indebted to any insurer or any insurance company or managing general agent?	YES NO

Do you intend to sellinsurance principally forthe purposeof placinginsurance on risks owned or controlled?	YES NO


Email Address

Year agency started		Years in employee benefits business:

Geographic area served by your agency:

Number of sales or account reps:		Number of Administrative/Support staff:
Client size (# of lives) Individual	3 - 50 51-100 101-500 501 +