AGREEMENT AND RECEIPT. The undersigned employer hereby adopts and subscribes to the terms and provisions in the application and to the terms and provisions of the Policy of which this application becomes a part. It is agreed that the employer has 15 days (30 days in NH) from the date of delivery of the Policy to return the Policy to Renaissance’s corporate headquarters for a full refund. If the employer exercises this right, the Policy will terminate on the Effective Date as if no coverage was ever in force, and all money received will be returned. In addition to the commissions and/or fees identified specifically for your benefit plan, the Agency or Agent may qualify for additional compensation payments from Renaissance related to your purchase of a Renaissance Policy. This additional compensation is not charged to your group. This application is subject to approval in accordance with Renaissance’s guidelines. Misrepresentation of material fact within the first two years from the date of issue or reinstatement of this Policy will cause this application and subsequent Policy to be null and void from the start. Any person who, with intent to injure, defraud or deceive an insurer or an insurance claimant, submits an applica- tion or files a claim containing a false or deceptive statement is guilty of a crime (Class H felony) which MAY subject the person to criminal and civil penalties. This type of plan in NOT considered “minimum essential coverage” under the Affordable Care Act and therefore does NOT satisfy the individual mandate that you have health insurance coverage. If you do not have other health insurance coverage, you may be subject to a federal tax penalty. THIS POLICY PROVIDES DENTAL AND/OR VISION BENEFITS ONLY. REVIEW YOUR POLICY CAREFULLY. Check # in the amount of $ to be applied as a credit toward the payment of the first month’s premium on the proposed Renaissance Policy for which application is made. In case application is not accepted by Renaissance, the payment indicated here will be returned. Signed this: day of , 20 at Signature of Authorized Group Official: Title: Signature of Agent: License # : State: Signature of Renaissance Representative: Underwritten by Renaissance Life & Health Insurance Company of America, PO Box 1596, Indianapolis, IN 46206.
AGREEMENT AND RECEIPT. This document contains the full and entire Agreement between Client and Broker. Each acknowledges receipt of a copy of this Agreement. AMENDMENT This Agreement may not be amended or modified except in a writing that is signed by the parties hereto. Buyer's Edge Company, Inc. Client date 0000 Xxxxx Xxx. Xxxxxxxx, XX 00000 000-000-0000 Print Name Client date Authorized Agent date Print Name CLIENT INFORMATION Client name: Client address: Client phone: Client email: CLIENT INFORMATION Client name: Client address: Client phone: Client email:
AGREEMENT AND RECEIPT. The undersigned employer hereby adopts and subscribes to the terms and provisions in the application and to the terms and provisions of the contract of which this application becomes a part. It is agreed that the employer has 15 days from the date of delivery of the contract to return the contract to Renaissance’s corporate headquarters for a full refund. If the employer exercises this right, the contract will terminate on the effective date as if no coverage or administrative services were ever in force, and all money received will be returned. This application is subject to approval, refusal, or modification in accordance with Renaissance’s guidelines. Misrepresentation or fraud will cause this application and subsequent contract to be null and void from the start. Any person, who knowingly and with intent to injure, defraud, or deceive any insurer, or files a statement of claim or an application containing false, incomplete, or misleading information is guilty of a felony of the third degree. Any person, who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose or misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Check # in the amount of $ to be applied as a credit toward the payment of the first month’s premium on the proposed Renaissance program for which application is made. In case application is not accepted by Renaissance, the payment indicated here will be returned. Signed this day of , 20 at Signature of Authorized Group Official Title Signature of Agent Lic. # State
AGREEMENT AND RECEIPT. This document and attachments contain the full and entire Agreement between Buyer and Broker and supersede any prior or contemporaneous agreements, if any, whether written or oral between the parties, except as checked in Paragraph 5. Each acknowledges receipt of a copy of this Agreement. This Agreement may not be cancelled or modified except in writing that is signed by the parties hereto. Buyer Buyer Broker (name of real estate firm) By: Buyer Agent of Broker Address City State Zip
AGREEMENT AND RECEIPT. This document and attachments contain the full and entire Agreement between Buyer and Broker and supersede any prior or contemporaneous agreements, if any, Each acknowledges receipt of a copy of this Agreement. This Agreement may not be canceled or modified except in writing that is signed by the parties hereto. Buyer(s): Buyer Broker: Oz Realtors® LLC _____________________________________ By: _____________________________________
