Transamerica Agent And Commission Form
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1
2Transamerica Life Insurance Company
Agent and
P.O. Box 8063
Commission
Little Rock, AR 72203-8063
Phone: 800-400-3042
Form
Fax: 800-235-4790
PRODUCT INFORMATION
UL - TransLegacy
- High Face Amount
Accident - AccidentAdvance
Dental - TransSmile
SM
SM
®
UL - TransLegacy
- High Accumulation Value
Accident - AccidentSelect
Disability - TransDI
Plus
SM
®
SM
Whole Life - Trans$ure
ISWL
Accident - TransAccident
Disability - TransDI
Plus Preferred
SM
®
SM
Term Life - TAC$-Advantage
Cancer - CancerSelect
Plus
Disability - CasinoDI
®
®
Term Life - Voluntary Group Term (no advance)
Cancer - LIVESTRONG - Cancer
GAP - TransConnect
®
Term Life and Accident Combo - myPack
SM
Critical Illness - CriticalAssistance Select
®
GAP - HealthPak
SM
Critical Illness - HealthPak
CI Select
Limited Benefit - TransChoice
SM
®
Self-Administered Basic Term Life
Critical Illness - CriticalAssistance Plus
Limited Benefit - TransChoice
Plus
SM
®
Self-Administered Basic Short-Term Disability
Critical Illness - LIVESTRONG - Critical Illness
Other:
COMMISSION TYPE
Heaped Commissions
Level Commissions (Requires Home Office Approval)
Small Group
GROUP INFORMATION
Enclosed are __________ applications that are part of a:
Oldest Application Date:
New Group
Existing Group Re-enrollment
Existing Group New Location/Division
Existing Group New Product/Rider
Group Name:
Group Number:
Location:
Requested Effective Date:
ENROLLMENT INFORMATION
Domicile State:
States where enrollment will take place:
Method of Solicitation:
Face to Face
Call Center
Web
Other ___________________________
Method of Enrollment: (If electronic enrollment, refer to our Electronic Enrollment Guide for rules regarding electronic enrollments)
Paper
Electronic –vendor name ____________________________________________________________________
Will Signatures Be Captured Electronically?
No
Yes - Method of Signature:
PIN
Digitized Signature
Recorded Line
For Life Insurance enrollments only: Needs Analysis Pamphlets & Buyer’s Guides will be distributed by:
Employer
Enroller
DELIVERY INFORMATION
Check only one box for each item.
Master Contracts:
Agency
Employer
TPA
Administrative Kits:
Agency
Employer
TPA
Billing Statements:
Agency
Employer
TPA/PCA
Policies/Certificates: Policy/Certificateholder, unless state requirements apply.
Special Instructions:
AGENT INFORMATION
Account Service Schedule:
Monthly
Semi-Annually
Annually
Other (explain)
Servicing Agency Name:
Servicing Agency Number:
Servicing Agency Contact:
Broker of Record:
Servicing Agent Number:
Servicing Agency Contact Phone Number:
(If other than the servicing agency)
Enrollment Company:
Enrollment Company Contact:
Enrollment Company Contact Phone Number:
Premium Share %
Commission
Last Name
First Name
Agent #
(must = 100%)
Rate
Agent 1
%
%
Agent 2
%
%
Agent 3
%
%
Agent 4
%
%
Commission Split #1 applies to all products except:
,which will use Commission Split #2.
Agent 1
%
%
Agent 2
%
%
Agent 3
%
%
Agent 4
%
%
Broker of Record Name _____________________________
Broker of Record Signature _________________________________
Date __________________
TWM-ACF-100110
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