NPD Group Subscriber Agreement 2002


Published on

Plan I co-designed and implemented at NPD.

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

NPD Group Subscriber Agreement 2002

  1. 1. NEVADA PACIFIC DENTAL GROUP SUBSCRIBER AGREEMENT THIS CONTRACT dated this ______ day of _______, 2003 by and between NEVADAPACIFIC DENTAL, INC. (hereinafter referred to as "COMPANY") and _____________(hereinafter referred to as "ORGANIZATION") is made with reference to the following facts: A. COMPANY is a Nevada corporation whose primary purpose is to provide dental health care services. B. ORGANIZATION desires to obtain the services herein specified for and on behalf of its eligible participants as defined herein. C. NOW, THEREFORE, the parties mutually covenant and agree as follows:I. DEFINITIONS: A. "PLAN" shall mean those benefits, coverages and other charges as set forth herein. B. "ELIGIBLE PARTICIPANTS" shall mean employees, members, dependents or beneficiaries of ORGANIZATION who are eligible to participate in the Plan under the eligibility requirement set forth by ORGANIZATION. C. "MEMBER" shall mean an Eligible Participant who is actually enrolled in COMPANY. D. "DEPENDENT" shall mean the spouse and children of a MEMBER, as defined in Section VI.B. herein. E. "PROFESSIONAL PROVIDER" shall mean the dentist, under contract with COMPANY. F. "PREPAYMENT FEE" is the amount payable each month on a prepayment basis by a Member of the ORGANIZATION (or both) to obtain benefits provided under the Group Subscriber Agreement.gsanpd.1002-1008gsanpd.1010-1011copyright 2002 1
  2. 2. G. "COPAYMENT" means additional fee charged to a Member which is approved by the Nevada Division of Insurance, provided for in this Agreement and disclosed in the Evidence of Coverage or the Disclosure Form used as the Evidence of Coverage. H. "EXCLUSION" means any provision of the Group Subscriber Agreement whereby coverage for a specified hazard or condition is entirely eliminated. I. "LIMITATION" means any provision other than an exclusion which restricts coverage under the Group Subscriber Agreement. J. "GENERAL PRACTITIONER" means a dentist whom practices general dentistry and who does not hold him/herself out to be a specialist in a particular field of dentistry. K. "SPECIALIST" means an Dentist who is responsible for the specific specialized dental care of a Plan Member in one specific field of dentistry such as endodontics, periodontics, oral surgery, or orthodontics where the member is referred by a Professional Provider affiliated with the COMPANY. L. "SPECIFIC SPECIALIZED DENTAL CARE" means a treatment plan (dental care) diagnosed and administered to a particular patient, which a patient receives as a result of the referral to a Specialist by the Professional Provider affiliated with the COMPANY. M. "PREVAILING RATES" are the usual, customary and reasonable charges prevailing in the geographic area in which the Professional Providers office is located; a copy of such charges are to be kept at the Professional Providers office. N. "BENEFITS and COVERAGE" means the dental care services available under the Group Subscriber Agreement in which a member is enrolled. O. "EMERGENCY CARE" means services required for alleviation of severe pain or bleeding and/or immediate diagnosis and treatment of unforeseen conditions, which, if not immediately diagnosed and treated may lead to disability, dysfunction or death. P. "AESTHETIC DENTISTRY" means any dental procedures which are performed purely for cosmetic purposes, and where there is not restorative value.gsanpd.1002-1008gsanpd.1010-1011copyright 2002 2
  3. 3. Q. "ELECTIVE DENTISTRY" means any dental procedures that are unnecessary to the dental health of the patient, as determined by a Plan Dentist. R. "SERVICE AREA" means a geographical area designated by the Company within which the Company shall provide services.II. PRINCIPAL BENEFITS, SERVICES, COVERAGES, COPAYMENTS AND OTHER CHARGES A. The COMPANY and ORGANIZATION agree that COMPANY shall provide coverage to Members of ORGANIZATION under the Plan as set forth in Exhibit A of this contract for the term of this contract.III. PRINCIPAL LIMITATIONS A. The limitations that are applicable to this COMPANY Plan are set forth in Exhibit B of this contract.IV. PRINCIPAL EXCLUSIONS A. The procedures and services that are not included in this COMPANY Plan are set forth in Exhibit C of this contract.V. COORDINATION OF BENEFITS In the event the Member has other dental coverage, benefits will be coordinated as follows: A. Whether the other coverage is a group or nongroup prepaid program, the Member may obtain covered services from a participating Professional Provider on either Plan, not both, and be subject to the appropriate copayments. B. If the Professional Provider is a participating dentist for both prepaid plan, he will charge the lesser of the two plans copayments applicable to the services rendered. C. If the other coverage is a group insurance program, the participating Professional Provider will provide covered services to the member at the copayments specified in the Program of Benefits and shall submit for insurance claims the amounts of the copayments specified in the Program of Benefits, and not his usual and customary fees.gsanpd.1002-1008gsanpd.1010-1011copyright 2002 3
  4. 4. D. If the other coverage is a nongroup insurance program, the Professional Provider may use his usual and customary fees for submitting insurance claims, but he may not collect more, from both the insurance payments and the Member payments combined, than the copayments specified in the Program of Benefits. The Member may, however, accept any insurance payment in excess of the copayment for a specified covered service.VI. ELIGIBILITY A. The determination of who is eligible to participate and who is actually participating in the Plan shall be decided by ORGANIZATION, as stated in Section I.B. herein, and the COMPANY shall have the right to rely on that determination. Any disputes or inquiries regarding eligibility, including rights regarding renewal, reinstatement and the like, if any, shall be referred by the COMPANY to ORGANIZATION, which shall then advise the COMPANY of its determination. B. Subject to all of the above eligibility requirements, the COMPANY guarantees the following: l. Dependents shall also include all newborn infants whose coverage shall commence from the moment of birth, and all adopted, foster and step children whose coverage shall commence from the date of placement. 2. Dependents shall include all unmarried children under the age of 19 years who are chiefly dependent on the Member for their support. Eligibility shall be extended for fulltime students under the age of 23 years, if unmarried and chiefly dependent on the Member for support. 3. Coverage shall not terminate while a Dependent child is and continues to be: a. Incapable of selfsustaining employment by reason of mental retardation or physical handicap; and b. Chiefly dependent upon the Member for support and maintenance, provided the Member furnishes proof of such incapacity and dependency to COMPANY within 31 days of the Dependentsgsanpd.1002-1008gsanpd.1010-1011copyright 2002 4
  5. 5. attaining the limiting age as set forth in Section VI.B.2. and every two years thereafter. 4. Should a Member be terminated or become ineligible for benefits, that member shall continue to be eligible to receive services and COMPANY shall be entitled to its monthly fee for that member until such time as the ORGANIZATION notifies the COMPANY in writing of the members termination or loss of eligibility and the member is removed from the eligibility list. Should COMPANY be notified of a members termination or loss of benefits after the eligibility list is provided or after the first of the month, coverage for that member shall continue until the end of the month and COMPANY shall retain or must be paid its monthly fee for that member to the end of the month.VII. INDIVIDUAL CONTINUATION OF BENEFITS A. Loss of Group Eligibility The Member who becomes ineligible for group coverage may apply within thirty (30) days of notice of ineligibility to continue Plan coverage. The terms and conditions under the Subscriber Agreement in which such Member was enrolled shall continue in effect with the following exceptions: Notices and distribution of materials as required will be delivered directly to the Member; Member shall pay the applicable monthly premium in effect at the time the application to continue coverage is approved by The COMPANY. Such extension of coverage shall apply to the Dependent(s) of the converting Members upon the same terms and conditions as applied to the converting Member. Such application may be accepted or rejected at the option of the COMPANY; no automatic right of individual continuation of benefits exist. B. Loss of Eligibility Due to Termination of Group Subscriber Agreement The COMPANY reserves the right to offer conversion privileges to the Member who becomes ineligible due to the termination of the Group Subscriber Agreement. Should such conversion be offered to the Member, application must be made within thirty (30) days of notice of ineligibility to continue Plan coverage. The terms and conditions under the Subscriber Agreement in which such member was enrolled shall continue in effect with the following exceptions: Notices and distribution of materials as required will be delivered directly to the Member; Member shall pay thegsanpd.1002-1008gsanpd.1010-1011copyright 2002 5
  6. 6. applicable monthly premiums in effect at the time the application to continue coverage is approved by the COMPANY. Such extension of coverage shall apply to the Dependent(s) of the converting member upon the same terms and conditions as applied to the converting Member. C. Conversion Upon Death or Divorce of a Member A spouse who is enrolled in the Plan who ceases to be a qualified family member by reason of termination of marriage or death of the member will be afforded to same conversion rights and conditions granted to the Member under paragraph A of this Section.VIII. CHOICE OF PROVIDER A. On the members enrollment form, each eligible participant who is eligible to receive services, shall select the particular Professional Provider the member wishes to go to for services provided for herein. Thereafter, to obtain services provided for herein, the member need only contact the selected Professional Provider. The member and dependents must all go to the same selected Professional Provider in order to receive services provided for herein. In the event a member is dissatisfied with any Professional Provider listed herein, for any reason and desires to transfer to another Professional Provider, the member may do so by contacting the COMPANY at the telephone numbers listed herein, and must execute a form supplied by the COMPANY. The transfer will be effective the first day of the following month after the receipt of the transfer form. B. By Nevada statute, every contract between the COMPANY and a Professional Provider shall provide that in the event the COMPANY fails to pay the Professional Provider, the Member shall not be liable to the Professional Provider for any sums owed by the COMPANY. C. In the event the COMPANY fails to pay noncontracting providers, the Member may be liable to the noncontracting provider for cost of services.IX. FACILITIES A Schedule of the COMPANYs participating Professional Providers is attached as Exhibit "D". These Professional Providers are open during normal business hours. Should a Member have a question regarding the days and/or hours of the Professional Providersgsanpd.1002-1008gsanpd.1010-1011copyright 2002 6
  7. 7. facility, he/she may write or call either the Professional Provider at the address and telephone number listed on the schedule or the COMPANY at the address and telephone number indicated in Section XIV.D. herein.X. PROFESSIONAL DOCTORPATIENT RELATIONSHIP A. It is expressly understood that the relationship between the member and the Professional Provider rendering services or treatment, shall be subject to the rules, limitations and privileges incident to the professional relationship, subject to the COMPANYs Peer Review Committee and Public Policy Committee. The Professional Provider shall be solely responsible without interference from the COMPANY or ORGANIZATION to the member for all services or treatment within the professional relationship. The Professional Provider shall have the right to refuse treatment to a member who continually fails to follow a prescribed course of treatment, who uses the relationship for illegal purposes, or makes the professional relationship onerous. B. While the COMPANY desires and will actively seek to maintain the most modern facilities available in the profession, it is understood and agreed that the operation and maintenance of the Professional Providers facilities, equipment and the rendition of all professional services shall be solely and exclusively under the control and supervision of the Professional provider, including all authority and control over the selection of the staff, supervision of personnel, and operation of the professional practice, and/or the rendition of any particular professional service or treatment. C. The COMPANY will undertake to see that the services provided to Members by its participating Professional Providers, shall be performed in accordance with professional standards of reasonable competence and skill of general practitioners prevailing in the county where each of its Professional Providers practice. D. Information from dental records of members and information received by Plan Providers incidental to the providerpatient relationship is kept confidential, except for use incidental to bona fide medical or dental research; or if reasonable and necessary for the administration of this contract. Access to all such information, will be granted to the Division of Insurance as required by the current state law.XI. GRIEVANCE PROCEDURESgsanpd.1002-1008gsanpd.1010-1011copyright 2002 7
  8. 8. A. Members are encouraged to contact the COMPANY at the following number, 18009260925 regarding any problems that are encountered while obtaining services. The COMPANY maintains a Member Grievance Procedure to deal with Member problems and complaints. Member complaints or grievances can be made in person, at any Professional Providers office or in writing. Grievance forms are available for this purpose at any Professional Providers office or from the COMPANY. There will be a representative at a Plan Providers office or at the COMPANYs main business office to aid the Member in filling out the grievance form. Completed grievance forms must be mailed to the COMPANYs main business office located at 1432 South Jones Blvd., Las Vegas, NV 89146. B. Members will receive a written response within thirty (30) days as to disposition of the complaint. C. Appeal of decisions from the Member Grievance Procedure must be made in writing to the Public Policy Committee of the Board of Directors within fortyfive (45) days from the time the Member is informed of a decision. Members will be informed in writing as to the disposition of the Public Policy Committee within thirty (30) days of an appeal.XII. ADMINISTRATION A. Upon obtaining a list of Members at the inception of this Agreement, the COMPANY shall cooperate with ORGANIZATION to issue identification cards or other data identifying each Member as being eligible for services. B. With respect to the distribution of materials, such as Evidences of Coverage, Disclosure Statements and other materials required to be distributed under the State regulation, or any regulations issued thereto, it shall be sufficient for the COMPANY to deliver such materials to the representative of ORGANIZATION designated in Section XVII of this Agreement. It shall then be ORGANIZATIONs responsibility to distribute such materials to its Members. C. Whenever the COMPANY is obligated to give any notice to members of ORGANIZATION with regard to any matters covered by this contract, State Regulation, or any regulations issued pursuant thereto by the Department of Insurance of the State of Nevada, it shall be sufficient for the COMPANY to give such notice to a representative of ORGANIZATION. ORGANIZATION shall then be obligated to give that notice to its members in their next regular communicationgsanpd.1002-1008gsanpd.1010-1011copyright 2002 8
  9. 9. but in no event shall such notice be given later than 30 days after the COMPANY gives such notice to ORGANIZATION. The group representative designated to receive such notice is indicated in Section XVII. Not withstanding the above, with respect to any notice of cancellation or refusal to renew mailed or hand delivered to the group representatives, such representative shall be required to mail promptly to each Member at Members current address, a legible, true copy of any such notice received from the COMPANY and shall provide promptly to the COMPANY proof of such mailing and the date thereof. ORGANIZATION shall provide promptly to the plan proof of such mailings and the date thereof of any notice required herein. D. Upon termination of a Dental Provider contract, the COMPANY shall be liable for covered services rendered by such Professional Provider (other than for copayments as defined in Section I.G.) to a Member who retains the eligibility under the plan contract or by operation of law under the care of such provider at the time of such termination until the services being rendered to the Member by such Professional Provider are completed, unless the COMPANY makes reasonable and medically appropriate provisions for the assumption of such services by a contracting Professional Provider. E. The COMPANY hereby agrees to duly investigate and try to resolve any and all complaints received from Members, in accordance with the grievance procedures outlined in Section XI. with regard to the quality of the Professional Providers services. Any inquiries, complaints or the like may be made by writing or by calling the COMPANY at the address and telephone number indicated in Section XV.D. herein.XIII. DURATION OF AGREEMENT, CHANGES, RENEWALS AND TERMINATIONS A. This Agreement shall be effective on the date indicated and shall continue for the term set forth in Section XV. (D) and XVI., respectively. B. The COMPANY may not increase the amounts paid by ORGANIZATION or Members, except after a period of sixty (60) days from either the date of mailing or actual hand delivery to the ORGANIZATION of written notice of such proposed increase. C. The COMPANY may not decrease the benefits stated in this contract in any manner, except after a period of sixty (60) days from either the date of mailing or actual handgsanpd.1002-1008gsanpd.1010-1011copyright 2002 9
  10. 10. delivery to the ORGANIZATION of written notice of such proposed decrease or change. D. The parties may renew this contract at the end of the term hereof, and by mutual consent modify or alter this contract; provided, however, that said modifications, amendments, alterations or renewals shall be in writing, duly executed by both parties hereto, and attached to this contract. Failure by either party to terminate this contract by giving the other party written notice prior to the termination date of this contract, shall automatically renew this contract for a like term as indicated in Section XVI. hereof. E. A Member may not be cancelled or refused renewal, except in the following instances: 1. ORGANIZATIONs failure to pay the fees for such coverage if at least 15 days have elapsed since the date of notification and billing. 2. Members fraud or deception in the use of the services or facilities of the COMPANY, or knowing permittance of such fraud or deception by another. 3 Members failure to establish a professional doctorpatient relationship with a Professional Provider. F. Pursuant to the Department of Insurance regulations, any Member who alleges his/ her enrollment has been cancelled or not renewed because of his/her health status or requirements for services may request review by the Department of Insurance. G. If the Department of Insurance determines that a proper complaint exists under the provisions of this Section, he shall then notify the COMPANY. Within 15 days after receipt of such notification, the COMPANY shall then either request a hearing or reinstate the Members enrollment. H. If, after a hearing, the Department of Insurance determines that the cancellation or failure to renew is contrary to the regulations, he shall then order the COMPANY to reinstate the Members enrollment. A reinstatement pursuant to this Subdivision shall be retroactive to the time of cancellation or failure to renew, and the COMPANY shall be liable for the expenses incurred by the Member involved for covered dental care services from the date of cancellation or nonrenewal to and including the date of reinstatement.gsanpd.1002-1008gsanpd.1010-1011copyright 2002 10
  11. 11. I. Termination shall be effective the last day of the month during which the 60day period, or 15day period if applicable, expires. The COMPANYs Professional Providers shall complete all procedures upon which treatment has commenced prior to the date of termination, pursuant to the terms of this Agreement. J. The COMPANY shall, within 30 days of termination of this Agreement, refund the prorated portions of the prepaid fees which correspond to an unexpired term for which payment has been received. The COMPANY shall be paid its fees to date of termination. K. Receipt by the COMPANY of the proper periodic payment after cancellation of this Agreement for nonpayment shall reinstate this Agreement as though it had never been cancelled, if such payment is received on or before the due date of the succeeding periodic payment. However, the COMPANY may avoid such reinstatement by one or more of the following methods: 1. Specifying in the notice of cancellation, that if payment is not received within 15 days of issuance of such notice, a new application will be required and a new contract issued or the original agreement reinstated; or 2. If such payment is received more than 15 days after issuance of the notice of cancellation, the COMPANY refunds such payment within 20 business days, or; 3. If such payment is received more than 15 days after issuance of the notice of cancellation, the COMPANY issues to ORGANIZATION within 20 business days of receipt of such payment, a new contract accompanied by written notice stating clearly those aspects in which the new contract differs from the cancelled contract in benefits, coverages and other aspects.XIV. GENERAL PROVISIONS A. In the event of any controversy or dispute between interested parties (which term includes the ORGANIZATION, a Member, a Dependent, or the heirsatlaw or personal representatives of a Member or Dependent, and COMPANY, its agents, Professional Providers, or Employees), whether involving a claim in tort, contract or otherwise, and including disputes which are not adequately resolved by the COMPANYs grievance procedures, shall be submitted to binding arbitration. Suchgsanpd.1002-1008gsanpd.1010-1011copyright 2002 11
  12. 12. arbitration may be initiated by any interested party but if the matter in dispute is one which is subject to review under the COMPANYs grievance procedures, arbitration may not be initiated until the completion of such procedures. All such claims, controversies and disputes shall be submitted to arbitration in accordance with the applicable rules of the American Arbitration Association. Judgment upon any award rendered by the arbitrator may be duly entered in any court in the State of Nevada, having jurisdiction thereof. The prevailing party shall be entitled to court costs and reasonable attorneys fees. B. The waiver by either of the parties of one or more defaults, if any, under this Agreement shall not be construed to operate as a waiver of any other or future default, either in the same condition or covenant or any other condition or covenant contained in this Agreement. C. Whenever it shall become necessary for either Party to serve notice on the other, respecting this Agreement, such notice shall be in writing and shall be served by certified mail. If addressed to the COMPANY, such notice shall be addressed as follows: NEVADA PACIFIC DENTAL, INC 1432 SOUTH JONES BLVD. LAS VEGAS, NV 89146 COMPANY Telephone Number: 1702737-8900 If addressed to ORGANIZATION, such notice shall be addressed as indicated in Section XVI of this Agreement. D. Throughout this Agreement the singular shall include the plural and the plural shall include the singular; the masculine shall include the feminine and the neuter, and the feminine and the neuter shall include the masculine. E. If any provision of this Agreement is held to be illegal or invalid for any reason, such decision shall not affect the validity of the remaining provisions of this Agreement, but such remaining provisions shall continue in full force and effect unless the illegality or invalidity prevents the accomplishments of the objectives and purposes of this Agreement.gsanpd.1002-1008gsanpd.1010-1011copyright 2002 12
  13. 13. F. The COMPANY is subject to the Health & Safety Code of the State of Nevada, and to regulations issued thereto by the Department of Insurance. Should either the law or the regulations be amended, such amendments shall automatically be deemed to be a part of this Agreement and shall take precedence over any inconsistent provisions of this Agreement. G. Any provision required to be in this Agreement by either the law or the regulations shall automatically bind the Parties, whether or not they are actually included in this Agreement. H. ORGANIZATION covenants and hereby agrees that it will not sell, assign or transfer this Agreement without the specific written consent of the COMPANY, and any such sale, assignment or transfer shall be null and void and shall act as a default against this Agreement. The consent of the COMPANY to any one sale, assignment or transfer shall not waive the COMPANYs right with respect to declining to consent to any other sale, assignment or transfer. As an exception to the provisions of this Section, either party may sell, assign or transfer its rights and delegate its duties hereunder to any entity into which it has merged or which acquires substantially all of its assets. I. This Agreement constitutes the entire Agreement of the Parties. There are no oral representations or agreements not embodied in this written Agreement. This Agreement may only be modified by a writing executed by both Parties. J. Each of the Parties hereby acknowledges that it has read this Agreement, understands its contents and executes it voluntarily. K. ORGANIZATION hereby represents that it has the authority under applicable law and its charter instrument to execute this Agreement and has passed all necessary resolutions giving it authority to do so. L. ORGANIZATION covenants and hereby agrees that it will not solicit, use, engage or contract with any of the COMPANYs Professional Providers for use in any manner whatsoever in any program other than a COMPANY Plan. M. Discrimination Prohibited: 1. The COMPANY shall not refuse to enter any contract or shall not cancel or decline to renew or reinstate any contract because of race, color, nationalgsanpd.1002-1008gsanpd.1010-1011copyright 2002 13
  14. 14. origin, ancestry, religion, sex, marital status, sexual orientation, handicap, or age of any contracting party, prospective contracting party, or person reasonably expected to benefit from any such contract as a Member or otherwise. 2. The terms of any contract shall not be modified and the benefits or coverage of any contract shall not be subject to any limitations, exceptions, exclusions, reductions, copayments, coinsurance, deductibles, reservations, or premium, price or charge differentials, or other modifications because of the race, color, national origin, ancestry, religion, sex, marital status, sexual orientation, or age of any contracting party, prospective contracting party, or person reasonably expected to benefit from any such contract as a Member or otherwise; except that premium, price or charge differentials because of the sex or age of any such individual and based on objective, valid and uptodate statistical and actuarial data are not prohibited.XV. PREPAYMENT FEES, COMMENCEMENT OF COVERAGE AND WAITING PERIOD A. ORGANIZATION hereby agrees to pay to the COMPANY the monthly fees indicated below per eligible participant for the duration of this Agreement commencing on _____________ ____, 2003. PREMIUM RATE Maxima Plan Employee Only $16.76 Employee Plus One $30.80 Employee & Dependents $56.31 B. Payment of the monthly periodic fees indicated above shall be sent to the COMPANY and shall be paid by the ORGANIZATION. C. ORGANIZATION shall send payment to the COMPANY each month at its principal place of business as indicated in Section XV.D. herein to cover eligible participants. Said check shall be accompanied by an eligibility listing of the names, addresses, and other identifying data of all Eligible Participants and Members to be covered in the succeeding month. Said listing shall be provided to the COMPANY no later than the 20th day of the month preceding the month of coverage, and it shall specifically identify the following:gsanpd.1002-1008gsanpd.1010-1011copyright 2002 14
  15. 15. 1. All new Eligible Participants to be covered. 2. All current Members covered. 3. All Members who are no longer eligible to receive benefits. Should said list not arrive by the first of the month for the subsequent month of coverage, the COMPANY will assume all members from the previous month are eligible and will issue an eligible for benefits list to the professional providers. D. Coverage shall commence on the day of , 2003. E. Any applicable waiting period is indicated as the first of the month following a collection of one months premium.XVI. TERM OF AGREEMENT A. This Agreement shall continue in effect for a period of one (1) year from the date set forth in Section XV.D. NOW, THEREFORE, we set our hands and official seals this date first above written.NEVADA PACIFIC DENTAL ORGANIZATIONBy: B y :Title: Vice President - Operations Title:Date: Date:gsanpd.1002-1008gsanpd.1010-1011copyright 2002 15
  16. 16. A d d r e s s :AGENT, BROKER, PRODUCER OF RECORDNameCompanyStreet AddressCITY, STATE, ZIPAgent’s Phone NumberFederal I.D. # / Social Security #gsanpd.1002-1008gsanpd.1010-1011copyright 2002 16
  17. 17. Nevada License # / Type of LicenseCommission Check Payable To:NameStreet Address (if different than above)CITY, STATE, ZIPNevada License # / Type of Licensegsanpd.1002-1008gsanpd.1010-1011copyright 2002 17