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                                            Producer Type
                                             
                                            
                                                
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                                                        You are requesting a contract with International Medical Group®, Inc. and its affiliates, iTravelInsured, Inc. and International Medical Adminstrators, Inc.
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                                                        Please select one of the options listed below to signify the appropriate producer type to which you are requesting a contract:
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                                                         *License Required: Life & Health or Accident & Health (U.S. State + FL resident/non-resident) (Non-U.S. – Caribbean) 
                                                        **License(s) Required: Property & Casualty, and/or Travel or Limited Lines Travel (license is determined by state) 
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                                            Personal Identification Information
                                             
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                                            First Name * 
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                                            Last Name * 
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                                            Middle Initial 
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                                            Suffix ( Jr. I, II, III ) 
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                                            Date of Birth * 
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                                            Business Address
                                             
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                                            Agency / Entity Name * 
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                                            Business Country * 
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					| Business State * 
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					| Business Province * 
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                                            Business Address * 
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                                            Business City * 
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                                            Business Postal Code * 
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                                            Business Phone * 
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                                            Business Email * 
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                                            Fax Number 
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                                            Website 
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					| Preferred Mailing Address * | 
				 
                                    
                                        
                                             
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                                            License Information
                                             
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					| Country Licensed * 
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					State Licensed * 
                                             
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					| License Number * 
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                                                If Non-US where license is not applicable please enter N/A
                                             
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					NPN Number * 
                                             
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                                                If Non-US where NPN is not applicable please enter N/A
                                             
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					| Tax Reporting Information | 
				 
                                    
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COMPENSATION SCHEDULE  Commissions and renewal commissions equal to the percentages shown shall apply to premiums received on Certificates placed in force under this Producer Agreement (Agent) during the effectiveness of this Schedule, excluding applicable taxes, if any. Commissions and renewal commissions, bonuses or other compensation which IMG pays directly to Sub-Producers or their executors, administrators, surviving spouses, or estates.     | Product |  
            Commission (%) 
            Certificate Year 1
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            Renewal commissions (%) 
            Certificate Years 2 plus
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            Affiliates 
            Referral Fee Per referral
             |     | Patriot Series |  10 |  N/A 
            (Patriot Series extensions and renewals are considered at 1st year commision rate) |  
            $15 Standard 
            $25 Platinum
             |     | Global Series |  15 |  5 |  $100 |     | GEO / GEM & Patriot Group Exchange Annual Plan |  6 (Dental 4%) |  6 (Dental 4%) |  N/A |     | Travel Insurance Series |  10 |  N/A |  $10 Lite 
            $12 SE 
            $25 LX |          
Monthly Commissions are calculated using the following formula:        | Monthly Gross Premium |  - |  Applicable Surplus Lines Taxes |  X |  Commission Percentage |  = |  Gross Commission |     | Example: $1,000 |  - |  70 |  X |  1% |  = |  $9.30 |      
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                                            Signature * 
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                                            Password * 
                                             
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                                            Confirm Password * 
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