Contract Checklist for General Agent (Individual)

Individual/Entity Name: ___________________________________________________

REQUIRED DOCUMENTS FOR CONTRACTING

General Agent Agreemento Signature Page Signed & Datedo Full Name Printed or Typedo Tax Identification Number Section Completedo Certification Section Completed, Signed & Datedo Return Signature Page Only

Background & Information Sheeto Personal Section Completedo Business Section Completedo Background Experience Questions 1 and 2 Answeredo Answering “YES” to either question requires a written, signed and dated explanation.o Signed & Dated

Fair Credit Reporting Act Disclosureo Signed & Dated

Direct Deposit Authorization (Optional)o Completed, Signed & Datedo Voided Check or Deposit Slip Attached

Current State Licenseso ALL States in Which General Agent Will Be Soliciting Business

NOTE: For contracted entities who will not sell, solicit, negotiate or hold themselves out as an insuranceagency, no license is required except in the following states:

Corporations: GA MA MT NM PA PR UT VA

Individuals: GA KS MA MT NM PA PR UT VA

Florida Counties (if applicable*)*The state of Florida requires that non-resident producers physically soliciting business in FL counties must also holdappointments in each of those counties. Please mark one of the following:

Producer will not be physically soliciting in Florida ORProducer will be physically soliciting in the following Florida Counties ___________________.

ALL MATERIALS MUST BE RETURNED TO YOUR MASTER

GENERAL AGENCY TO CONTINUE THE CONTRACTING PROCESS

Master General Agency: Transmittal Form(s) must accompany all General Agent contracting

paperwork.

CML_General Agent_1011

PLEASE NOTE

10-2011 1 BMO02C.002

General Agent Agreement

This General Agent Agreement (“Agreement”) is between the undersigned General Agent (“GA”) andColumbian Mutual Life Insurance Company (“Company”).

See Section K for definitions.7

The parties agree as follows:A. Appointment Company authorizes GA to solicit

Product applications and to recruit Other GeneralAgents. Company agrees to appoint GA with theappropriate state insurance departments for GA tosolicit Product applications. This appointment is notexclusive.

B. Compensation.

1. For Each Product. GA’s compensation dependson the particular Products sold. Compensation foreach Product will be as specified in theCompensation/Product Schedules.Compensation/Product Schedules may bechanged by Company at any time and will bedistributed to GA.

2. Contingencies. In addition to any conditionsimposed in the Compensation/Product Schedulesand any amendments, no compensation is earneduntil:

(a) GA is licensed and appointed in accordancewith laws and Company procedures,

(b) the Product is actually issued, delivered toand accepted by the customer, and

(c) the premium for the Product is paid to theCompany.

3. Compensation After Termination. GA shallnot be entitled to any compensation after theTermination Date of this Agreement, except for:

(a) Vested Compensation, and

(b) any net credit balance in GA’s account forcompensation earned as of the TerminationDate.

4. Forfeiture. GA will forfeit all rights to receivecompensation, including Vested Compensation,if, in the sole reasonable discretion of Company,GA commits any of the following acts:

(a) breaches any material provision of thisAgreement while in effect or any materialobligation that survives termination of thisAgreement.

(b) commits a fraudulent or illegal act inconnection with any activities contemplatedunder this Agreement.

(c) does any act which results in the suspensionor revocation of GA’s insurance license.

C. GA’s Duties.

1. Licenses and Approvals. GA shall obtain andmaintain and provide copies of all necessarylicenses and regulatory approvals to perform theservices under this Agreement.

2. Monitor and Communicate. GA may recruitOther General Agents. GA shall monitor itsOther General Agents and communicateinformation to Company, of which it is aware orshould be aware, that Company needs to knowabout its Other General Agents to properlyaddress compliance or other risks. Whendirected by Company, GA shall communicateCompany information to its Other GeneralAgents.

3. Solicitation. GA shall help its Other GeneralAgents in soliciting Products. If GA iscontracting as an individual, then GA may solicitapplications for Products.

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4. Service. GA shall help its Other General Agentsin servicing customers. If GA is contracting asan individual, GA shall provide service to GA’scustomers.

5. Confidentiality and Privacy. GA shall complywith the “Confidentiality and PrivacyAmendment” which is attached hereto andincorporated into this Agreement. Company mayunilaterally revise the Confidentiality andPrivacy Amendment upon written notice to GA.

6. Compliance with Laws and Conduct. GA shallcomply with all applicable laws and regulationsand act in an ethical, professional manner inconnection with this Agreement, including,without limitation, with respect to anycompensation disclosure obligations and anyother obligations it may have governing itsrelationships with its clients.

7. Compliance with Company Policies. GA shallcomply, and shall ensure its employees comply,and shall instruct and encourage its OtherGeneral Agents to comply with all policies,practices, procedures, processes and rules ofCompany. GA shall promptly notify Company ifGA or any of its employees or Other GeneralAgents are not in compliance with any Companypolicy, procedure, process or rule.

8. Insurance. GA shall have and maintain Errorsand Omissions liability insurance covering GAand GA’s employees during the term of thisAgreement in an amount and nature, and withsuch carrier(s) satisfactory to Company andprovide evidence of such insurance to Companyupon request.

9. Fiduciary Responsibilities. GA shall beresponsible for all money collected by GA, GA’semployees and its Other General Agents onbehalf of Company and shall remit to Companyall payments and collections received for orpayable to Company from Other General Agents,applicants, customers, or others no later than 15days after receipt, or within any shorter periodrequired by law. All money tendered as paymentshall always be the property of Company andshall be held by GA purely in a fiduciarycapacity and not for GA’s own benefit. GA isnot authorized to spend, cash or deposit for anypurpose any portion of such money.

10. Records. Except as provided in theConfidentiality and Privacy Amendment, GAshall keep regular and accurate records of alltransactions related to this Agreement for aperiod of at least five years from the date of suchtransactions, or longer if required by federal orstate law or regulation.

11. Advertising Materials. GA shall obtainCompany’s written approval prior to using anyadvertising material or script identifyingCompany or Products, except such materialprovided by Company and used pursuant toCompany’s instructions.

12. Notice of Litigation or Regulatory Proceeding.GA shall promptly notify Company uponreceiving notice of potential, threatened, or actuallitigation or any regulatory inquiry or complaintwith respect to this Agreement or any Product.Company shall have final decision-makingauthority to assume the administration anddefense of any such action. A copy of thecorrespondence or document received shallaccompany each notice.

13. Delivery of Documents to Customers. Uponrequest from Company, GA shall deliver to itscustomers any information that Companyprovides to GA for the purpose of fulfillingCompany’s obligation to provide suchinformation to the customer, including withoutlimitation, Schedule A to Form 5500 and anyother information relating to compensation paidto GA by Company. GA shall deliver suchinformation to its customers within the timeperiod required by ERISA or other applicablelaw or as otherwise instructed by Company.

D. Limitations. GA, either directly or through itsemployees or Other General Agents, shall not:

1. Expense or Liability. Incur any expense orliability on account of, or otherwise bindCompany without specific prior written approvalfrom an Authorized Representative.

2. Alteration. Alter any advertising materials ormake, alter, waive or discharge any contracts orProducts on behalf of Company.

3. Premium Payments and Reinstatement.Extend the time for payment of any premium orwaive any premium, or bind Company toreinstate any terminated contract, or accept

10-2011 3 BMO02C.002

payment in any form other than a customer checkor money order payable to the Company or othermethod authorized by Company.

4. Respond in Connection with Proceeding.Institute or file a response to any legal orregulatory proceeding on behalf of Company inconnection with any matter pertaining to thisAgreement or any Product, without Company’sprior written consent.

5. Replacement. Replace any existing insuranceproduct or annuity contract unless thereplacement is in compliance with all applicablelaws and regulations and is in the best interest ofthe customer. The decision whether to replace aninsurance product or annuity contract should bemade by the customer. To help the customermake a decision regarding any proposedreplacement, GA must provide the customer withfull disclosure (both positive and negative) of allrelevant information.

6. Misrepresentation. Misrepresent or induce anyOther General Agent to misrepresent, anyprovision, benefit, or premium of any Product.

E. Compensation Administration.

1. Accounting. Company will account to GA forpayable commissions based upon initial andrenewal premiums received and accepted byCompany for policies issued upon applicationssubmitted by or through GA. Company reservesthe right to freeze GA’s account for a reasonableperiod of time to ensure that funds are availableto reimburse the Company for any Indebtedness.

2. Effect of Return of Premium. Except whereprovided on a Compensation/Product Schedule, ifany premiums shall be returned by Company onany policy or contract, or should Companybecome liable for the return thereof for any causeeither before or after the Termination Date, GAshall pay to Company all compensationpreviously paid or credited to GA’s account onsuch returned premium.

3. Set-Off. Company is authorized to set-off andapply any and all amounts due to GA fromCompany under this Agreement to any and allobligations or Indebtedness of GA or itsemployees, Other General Agents or affiliates toCompany or its affiliates. This right of set-offdoes not require Company to make any prior

demand upon GA, and the right existsirrespective of whether the obligations of GA orits affiliates are contingent or unmatured. Therights of the Company under this Section E.3 arein addition to any other rights and remedieswhich the Company may have under thisAgreement or otherwise.

4. Interest. Interest will accrue on any amount dueunder this Agreement, which has not been paidwithin 30 days of receipt of written demand forsuch amount at the rate of one percent per month,or the highest rate permitted by law, whichever islower.

5. Limitation of Compensation Actions. Anyclaim by GA regarding compensation must bebrought within one year from the date thecompensation was reported on an accountingissued from Company to GA. Any claimregarding compensation must be brought againstthe corporation which issued theCompensation/Product Schedule to which theclaim relates.

F. Termination With or Without Cause. In additionto the termination provisions set forth in theConfidentiality and Privacy Amendment, GA orCompany shall have the right at any time to terminatethis Agreement, with or without cause, upon writtennotice to the other party. Termination shall beeffective as of the Termination Date.

G. Independent Contractor. GA is an independentcontractor and not an employee of Company. Subjectto legal and regulatory requirements, GA shall be freeto exercise GA’s own judgment as to the personsfrom whom GA will solicit and the time and place ofsuch solicitation.

H. Inspection of Books and Records. Company shallhave the right, during normal business hours and withreasonable notice, to inspect, audit and make copiesfrom the books and records of the GA for the purposeof verifying GA’s compliance with the provisions ofthis Agreement.

I. Indemnity and Hold Harmless. Each party shallindemnify and hold the other party harmless fromany liability, loss, costs, expenses (includingreasonable attorneys’ fees incurred by theindemnified party) or damages, including punitiveand extra-contractual damages, resulting from any actor omission of its obligations provided in thisAgreement by the indemnifying party or any of its

10-2011 4 BMO02C.002

employees or Other General Agents in theperformance of its duties under this Agreement orother agreements with Company, including withoutlimitation, any breach of its obligations providedunder this Agreement.

J. General.

1. Issue and Product Type. Company shall retainthe right to decide whether to issue or withdraw aProduct and determine the type of Product to beissued or withdrawn. Company may discontinueor change a Product at any time.

2. Producer of Record. The producer of record forany Product shall be determined by Companyrecords. Company reserves the right to changethe producer of record according to Companyprocedures and shall have no obligation todesignate a successor producer of record.

3. Notice. Any notice required or permitted to besent to Company under this Agreement shall bedelivered personally or sent by U.S. Mail with allpostage prepaid or by express mail to:

Columbian Mutual LifePO Box 2620Omaha, NE 68103-2620

4. Entire Agreement. This Agreement, theConfidentiality and Privacy Amendment and theCompensation/Product Schedules constitute theentire agreement between the parties regardingthe Products sold under this Agreement.

5. Governing Law. This Agreement shall begoverned by the laws of the State of New York,without giving effect to that State’s principles ofconflicts of law.

6. Severability. In the event any provision of thisAgreement is found to be invalid orunenforceable, the remaining provisions shallremain in effect.

7. No Waiver. Failure of Company to enforce anyprovision of this Agreement shall not operate towaive or modify such provision or render suchprovision unenforceable.

8. No Assignment or Change. Except forCompensation/Product Schedules,Confidentiality and Privacy Amendments andother amendments to the Agreement which are

required by federal, state or local laws orregulations, no modification, amendment orassignment of this Agreement shall be validunless approved in writing by an AuthorizedRepresentative. Compensation/ProductSchedules, Confidentiality and PrivacyAmendments and other amendments to theAgreement which are required by federal, state orlocal laws or regulations may be distributed onlyby Company but need not be signed by eitherparty to be effective.

9. Survival. GA’s appointment pursuant to SectionA of this Agreement shall immediately terminateon the Termination Date. Except for SectionsC.2 and C.3 of this Agreement, all otherprovisions of this Agreement shall survive itstermination.

10. Beneficiary. If GA is an individual, then GAdesignates the beneficiary specified on thesignature page or such other party or parties asGA may designate by written notice delivered toand recorded by Company, as beneficiary forpayment of any compensation becoming dueafter GA’s death.

11. Headings. Any section or other headingcontained in this Agreement are for referencepurposes and convenience only and shall notaffect, in any way, the meaning and interpretationof this Agreement.

12. Counterparts. This Agreement may beexecuted in counterparts, each of which shall bedeemed an original, but all of which togethershall constitute one and the same instrument.

K. Definitions. The following terms have the followingmeanings. Any singular word shall include anyplural of the same word.

1. “Authorized Representative” means the ChiefExecutive Officer or President of a Company oran individual authorized in writing by the ChiefExecutive Officer or President.

2. “Compensation/Product Schedule” means aCompany’s distributed commission schedule that(a) specifies the amounts and conditions underwhich commissions will be due and payable toGA for any Product, and (b) is made a part of thisAgreement.

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3. “Indebtedness” means any amounts owed byGA to Company, including but not limited to(a) the chargeback of any compensation paid orcredited to GA under this or any otherAgreement, if the monies on which suchcompensation was based are not collected or arerefunded by the Company, (b) any advancesmade by Company to GA, (c) any expensesincurred by the Company on behalf of GA, and(d) any amount paid by the Company, which inits determination resulted from fraud,misrepresentation or other improper conduct bythe GA.

4. “Other General Agent” means any individual ororganization, which (a) enters into a generalagent, representative or other marketingagreement with Company and (b) submitsProduct applications that designate GA.

5. “Product” means any insurance policy, contract,investment vehicle or other offering identified inany Compensation/Product Schedule.

6. “Termination Date” means the later to occur of(a) the date on which GA or Company sendswritten notice of termination to the other party, or(b) the date specified by GA or Company in awritten notice of termination to the other party.

7. “Vested Compensation” means compensationidentified as vested on a Compensation/ProductSchedule and that may be paid to GA after theTermination Date if (a) the policy related to theProduct remains in force, (b) the premiums forthe policy are paid to Company, and (c) if GA isthe writing agent, GA remains the producer ofrecord.

[Remainder of page intentionally left blank]

10-2011 6 BMO02C.002

General Agent

_______________________________________________Sign Name (required)_________________________________________________Print Name_________________________________________________Title_________________________________________________General Agent_________________________________________________Date_________________________________________________

Designated Beneficiary

Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. For individuals, this is your social security number. For other entities, it is youremployer identification number.Social Security Number Employer Identification NumberOR

CertificationUnder penalties of perjury, I certify that:L. The number provided is my correct taxpayer identification number, and

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

N. I am a U.S. person (a U.S. citizen or U.S. resident alien or a partnership, corporation, company or associationcreated or organized in the U.S. or under the laws of the U.S. or an estate (other than a foreign estate) or adomestic trust (as defined in Regulations section 301.7701-7)).

Certification instructions: You must cross out item 2 above if you have been notified by the IRS that you arecurrently subject to backup withholding because you have failed to report all interest and dividends on your taxreturn.The Internal Revenue Service does not require your consent to any provision of this document other than theabove-referenced certifications required to avoid backup withholding.

SignHere

Signature ofU.S. person

Date

10-2011 7 BMO02C.002

Columbian Mutual Life

Please do not complete this page. If approved, you will receive an executed copy of this contract page.

General Agent Agreement

_________________________________________________By

_________________________________________________Name

_________________________________________________Title

_________________________________________________Date

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CONFIDENTIALITY AND PRIVACY AMENDMENT

This Confidentiality and Privacy Amendment (this “Amendment”) is made part of and incorporated into the GeneralAgent Agreement between GA and Company (“Agreement”) and is effective on the later of March 1, 2010 or theeffective date of the Agreement. This Amendment revokes and replaces in its entirety any prior Confidentiality andPrivacy Amendment made a part of and incorporated into the Agreement. To the extent any provisions of the Agreementconflict with or are inconsistent with any provisions of this Amendment, the provisions of this Amendment shall control.All other terms and conditions of the Agreement not inconsistent with the terms of this Amendment shall remain in fullforce and effect.

A. Definitions. Except as otherwise defined, any and allcapitalized terms in this Amendment shall have thedefinitions set forth in the Agreement.

1. “Business Information” means the followingnonpublic business or financial informationwhether in written, oral or electronic form:information which relates to customers or thebusiness of Company including without limitation,sales and rate information, software, business plansand operating strategies, Product information, andmaterial identifying an association with theCompany. Business Information does not include(a) information similar to Business Informationwhich is independently owned and developed byGA or (b) information relating to direct or indirectcompensation payable, paid or provided to GAunder the Agreement.

2. “Confidential Information” means BusinessInformation and Personal Information.

3. “HIPAA Privacy and Security Rules” means theStandards for Privacy of Individually IdentifiableHealth Information at 45 CFR part 160 and 164and the Security Standards at 45 CFR part 160,part 162 and part 164, as may be amended fromtime to time.

4. “Information Security Breach” means theunauthorized acquisition, access, use, disclosure,transmittal, storage or transportation ofConfidential Information which is not permitted bylaw or by the terms of this Amendment, including,but not limited to, a Security Incident.

5. “Personal Information” means a first name orinitial and last name in combination with anydemographic, medical or financial informationsuch as age, gender, address, Social Securitynumber, past or present physical and mental healthcondition and treatment, debt status or history,income and other similar individually identifiable

personal information which is not publiclyavailable. The term “Personal Information”includes, but is not limited to, Protected HealthInformation.

6. “Protected Health Information” shall have thesame meaning as that assigned in the HIPAAPrivacy and Security Rules limited to theinformation created or received from or on behalfof Company.

7. “Representatives” means all directors, officers,employees, agents, consultants, subcontractors,professional advisors and affiliates of GA.

8. “Security Incident” means the attempted orsuccessful unauthorized access, use, disclosure,modification or destruction of information in, orinterference with system operation in, an electronicinformation system containing ConfidentialInformation.

B. GA’s Obligations Regarding ConfidentialInformation.

1. Confidentiality. GA agrees to retain allConfidential Information in strict confidence. GAwill not use, disclose, transmit, store or transportConfidential Information except for purposesrelated to GA’s performance of obligations underthe Agreement. GA is responsible to Company forany Information Security Breach by itsRepresentatives.

2. Reporting Unauthorized Use, Disclosure orInformation Security Breach. GA agrees to reporteach of the following to Company:

(a) any use, disclosure or Information SecurityBreach of Confidential Information notauthorized or provided for by the Agreement;and

A-2

(b) any successful Security Incident of which itbecomes aware.

Any report made pursuant to this Section(2)(b) shall be made as soon as possible, but inno event later than three (3) business daysfollowing the date that GA becomes aware ofsuch unauthorized use, disclosure, InformationSecurity Breach or successful SecurityIncident. GA shall take action(s) requestedby Company to mitigate any such unauthorizeduse, disclosure, Information Security Breach orSecurity Incident.

3. Return of Confidential Information. GA willpromptly return or destroy all ConfidentialInformation and retain no copies of it (a) upontermination of the Agreement, for any reason;(b) once the Confidential Information is no longerneeded to perform a service under the Agreement;(c) if the GA is not required by law to retain theConfidential Information; or (d) once theConfidential Information has been retained throughthe expiration of the GA’s record retentionrequirements. Upon written request of Company,the destruction or return of the ConfidentialInformation shall be confirmed in writing. If thereturn or destruction of the ConfidentialInformation is not feasible, the protections of theAgreement shall be extended for so long as GAmaintains the Confidential Information. GA’s useand disclosure of such Confidential Informationshall be limited to those purposes that make thereturn or destruction of the ConfidentialInformation not feasible.

4. Disposal of Confidential Information. GA agreesto maintain a security policy for the disposal ofpaper and any other media that containsConfidential Information that includes atechnology or methodology that will render theConfidential Information unusable, unreadable orindecipherable.

C. Permitted Uses and Disclosures of ConfidentialInformation by GA. Unless otherwise prohibited bythe Agreement, this Amendment or state or federallaws or regulations, GA may use, disclose, transmit,store and transport Confidential Information:

1. for the proper management and administration ofGA’s business, provided that the use, disclosure,transmittal, storage and transportation are requiredby law, or GA obtains reasonable assurances from

the entity or person to whom the ConfidentialInformation is disclosed that it will remainconfidential and be used, disclosed, transmitted,stored, or transported only as required by law orfor the purpose for which it was disclosed to theperson;

2. to carry out the legal responsibilities of GA; and

3. to its Representatives if the Representative is firstinformed of the confidential nature of suchinformation and the obligations set forth herein,and agrees to be bound thereby.

D. GA’s Additional Obligations Regarding ProtectedHealth Information. GA agrees as follows:

1. to implement administrative, physical, andtechnical safeguards that reasonably andappropriately protect the confidentiality, integrity,and availability of the electronic Protected HealthInformation that it creates, receives, maintains ortransmits on behalf of the Company.

2. at the request of and in the time and mannerdesignated by Company, to provide access toProtected Health Information to Company, or asdirected by Company, to an individual in order tomeet the requirements of the HIPAA Privacy andSecurity Rules.

3. to make any amendment(s) to Protected HealthInformation that the Company directs or agrees topursuant to HIPAA Privacy and Security Rules inthe time and manner designated by the Company.

4. to document any disclosure of Protected HealthInformation, and upon request in the time andmanner designated by Company make anyinformation about the disclosure of ProtectedHealth Information available to Company in orderfor Company to meet the accounting requirementsof the HIPAA Privacy and Security Rules.

5. to make its internal practices, books and recordsrelating to the use and disclosure of ProtectedHealth Information, available to the Secretary ofHealth and Human Services or to a state AttorneyGeneral for purposes of determining theCompany’s compliance with the HIPAA Privacyand Security Rules.

6. upon written request of Company, provideCompany a report of Security Incidents of which it

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becomes aware that are attempted but notsuccessful.

E. General Security Requirements. When storingConfidential Information, GA shall comply with thefollowing requirements:

1. GA shall have a written, comprehensiveinformation security program for the establishmentand maintenance of a security system covering itscomputers, including any wireless system, that, at aminimum, shall have the following elements:

(a) Secure user authentication protocols thatinclude:

(i) control of user IDs and other identifiers;

(ii) a secure method of assigning and selectingpasswords, or use of unique identifiertechnologies, such as biometrics or tokendevices;

(iii) control of data security passwords toensure that such passwords are kept in alocation and/or format that does notcompromise the security of the data theyprotect;

(iv) restricting access to active users and activeuser accounts only;

(v) blocking access to user identification aftermultiple unsuccessful attempts to gainaccess or limitation placed on access forthe particular system;

(vi) prohibitions against sharing or migratingaccess privileges to another individual; and

(vii) assignment of access privileges only toidentifiable, individual accounts, and allactivity conducted by these accounts mustbe auditable.

(b) Secure access control measures that:

(i) restrict access to records and filescontaining Confidential Information tothose who need such information toperform their job duties; and

(ii) assign unique identifications pluspasswords, which are not vendor supplied

default passwords, to each person withcomputer access, that are reasonablydesigned to maintain the integrity of thesecurity of the access controls.

2. To the extent technically feasible, GA will encryptall records and files containing ConfidentialInformation that are transmitted across publicnetworks or transmitted wirelessly.

3. GA will monitor systems for unauthorized use ofor access to Confidential Information.

4. GA will encrypt all Confidential Informationstored on laptops or other portable devices.

5. For files containing Confidential Information on asystem that is connected to the Internet, GA willmaintain up-to-date firewall protection andoperating system security patches designed tomaintain the integrity of the ConfidentialInformation.

6. GA will maintain up-to-date versions of systemsecurity agent software which includes malwareprotection and up-to-date patches and virusdefinitions, or a version of such software that canstill be supported with up-to-date patches and virusdefinitions, and is set to receive the most currentsecurity updates on a regular basis.

7. GA will educate and train employees on the properuse of the computer security system and theimportance of Confidential Information security.In addition:

(a) GA will designate one or more employees tomaintain the comprehensive informationsecurity program.

(b) GA will identify and assess foreseeableinternal and external risks to the security,confidentiality and/or integrity of anyelectronic, paper or other records containingConfidential Information, and will evaluateand improve, where necessary, theeffectiveness of their current safeguards forlimiting such risks, including but not limitedto: (i) ongoing employee (including temporaryand contract employee) training; (ii) employeecompliance with policies and procedures; and(iii) means for detecting and preventingsecurity system failures.

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(c) GA will maintain a security policy forRepresentatives that protects recordscontaining Confidential Information that aretransported outside of business premises.

(d) GA will impose appropriate disciplinarymeasures for employees that violate theircomprehensive information security programrules.

(e) GA will have processes in place to preventterminated employees from accessing recordscontaining Confidential Information byimmediately terminating their physical andelectronic access to such records, includingdeactivating their passwords and user names.

F. PCI-DSS Requirements. GA will not store any creditor debit card data. If GA transmits any credit or debitcard data for any reason pursuant to the terms of theAgreement or this Amendment, GA will employsafeguards that comply with the Company’s policiesand the Payment Card Industry Data Security Standard(PCI-DSS), as may be amended from time to time, orotherwise protect the data by adequately securing itstransmission.

G. General Provisions.

1. Compliance with Laws. GA shall comply with itsobligations under the Agreement, this Amendmentand under any applicable state or federal law orregulations as may be in effect or as may hereafterbe enacted, adopted or determined regarding theconfidentiality, use, disclosure, transmittal, storageor transportation of Confidential Information.

2. Amendment. This Amendment shall be amendedto conform to any legal requirements that resultfrom any changes, revisions or replacements of anyapplicable state or federal law or regulation as maynow be in effect or as may hereafter be enacted,adopted or determined regarding the

confidentiality, use, disclosure, transmittal, storageor transportation of Confidential Information,including, without limitation, the HIPAA Privacyand Security Rules, on or before the effective datethereof. Company may change, revise or replacethis Amendment in its sole discretion upon noticeto GA without the consent of GA. In the event of aconflict between the requirements of thisAmendment and those of the HIPAA Privacy andSecurity Rules, the HIPAA Privacy and SecurityRules shall control.

3. Disclosures Required By Law or a GovernmentalAuthority. If either party is required to discloseConfidential Information in response to legalprocess or a governmental authority, such partyshall immediately notify the other party and, uponrequest, cooperate with the other party inconnection with obtaining a protective order. Thedisclosing party shall furnish only that portion ofthe Confidential Information which it is legallyrequired to disclose and shall use commerciallyreasonable efforts to ensure that confidentialtreatment shall be accorded such ConfidentialInformation.

4. Survival. The respective rights and obligations ofGA under this Amendment shall survive thetermination of the Agreement.

5. Cost of an Information Security Breach. GAshall be responsible for the costs associated with anInformation Security Breach that results from thefailure of GA's information security program orGA’s failure to comply with federal or state laws.GA will cooperate with Company to mitigate anydamages that may result.

6. Termination for Violation of this Amendment.Company may terminate the Agreement, effectiveimmediately upon notice to GA, if GA has violatedthe terms of this Amendment.

CMLINFO 2-2010

BACKGROUND AND INFORMATION SHEET

Name:

Social Security Number: Date of Birth:

Home Address (must be a physical street address):

Home Phone: Cell Phone:(optional)

E-mail Address:(optional)

Business Name:(if applicable)

Personal Business Address:*Note – All correspondence (including compensation statements), will be mailed to the personal business addressindicated. Only one business address is supported per individual. If no business address is indicated, mail will bedirected to home address.

Address for overnight packages (cannot be a P.O. Box):

Business Phone: Business Fax:

Tax I.D. Number: E-mail Address:

Please identify your Master General Agency (if applicable):

Candidate Signature Date

BACKGROUND EXPERIENCE. Note: Please read each question carefully. Failure to answer “Yes”below, when appropriate, may result in the denial of your request to be contracted.

1. Have you ever been fined, suspended, placed on probation, paid administrative costs, entered into a consentorder, been issued a restricted license or otherwise been disciplined or reprimanded, or are you currentlyunder investigation by any insurance department, FINRA (formerly known as the NASD), SEC or any otherregulatory authority?__________Yes_________No

2. Have you ever been convicted or plead guilty or nolo contendere (no contest), served any probation, paidany fines or court costs, had charges dismissed through any type of first offender or deferred adjudication orsuspended sentence procedure, or are any charges currently pending against you for any offense other than aminor traffic violation?__________Yes_________No

PROVIDE A WRITTEN EXPLANATION AND APPLICABLE SUPPORTING DOCUMENTATION (i.e.,court documents, insurance department documents, etc.) FOR ANY QUESTION TO WHICH YOURESPONDED “YES”. Please be sure to date and sign the written statement.

CMLFCRA 2-2010

FAIR CREDIT REPORTING ACT DISCLOSURE

Columbian Mutual Life Insurance Company will obtain and use consumer reports for the purpose of serving as a factorin establishing your eligibility for contracting as an insurance producer. We will obtain these consumer reports from:

First Advantage Corporation100 Carillon Parkway, Suite 100

St. Petersburg, FL 33716

“Consumer report” means a written, oral or other communication of any information by a consumer reporting agencybearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristicsor mode of living which will be used by Columbian Mutual Life Insurance Company, in whole or in part for the purposeof serving as a factor in establishing your eligibility to be contracted as an insurance producer.

This means a credit report, criminal report and report of insurance department regulatory actions will be obtained andreviewed as part of a background investigation in order to determine your eligibility to be contracted and appointed.

For California, Minnesota and Oklahoma: You have a right to request a copy of the consumer report which willdisclose the nature and scope of the report.

Yes, please provide me a copy of the consumer report

For New York: You have a right, upon written request, to be informed of whether or not a consumer report wasrequested. If a consumer report is requested, you will be provided with the name and address of the consumer reportingagency furnishing the report.

CANDIDATE’S STATEMENT – READ CAREFULLY

Columbian Mutual Life Insurance Company is hereby authorized to obtain and use a consumer report of my criminalrecord history, insurance department history and credit history through any consumer reporting agency or throughinquiries with my past or present employers, neighbors, friends or others with whom I am acquainted. I understand thatthis consumer report will include information as to my general reputation, personal characteristics and mode of living.

AUTHORIZATION

I authorize any consumer reporting agency, insurance department, law enforcement agency, the Financial IndustryRegulatory Authority, The Securities and Exchange Commission or any other person or organization having anyconsumer report records, data or information concerning my credit history, public record information, insurance license,regulatory action history or criminal record history to furnish such consumer report records, data and information toColumbian Mutual Life Insurance Company.

I understand that if contracted, this authorization will remain valid as long as I am contracted with Columbian MutualLife Insurance Company.

A photocopy of this authorization shall be considered as effective as the original.

Candidate Signature Date

Print Name

Direct Deposit Authorization

I, the undersigned, do hereby authorize Mutual of Omaha and its affiliates to deposit my check asindicated below. This authority is to remain in full force and effect until Mutual of Omaha and itsAffiliates have received notification from me of its termination in such time and in such manner asto afford Mutual of Omaha and its affiliates a reasonable opportunity to act on it. In no event shallit be effective with respect to entries processed prior to receipt of notice.

I also understand this is not an assignment of commissions, 1099’s will continue to be issued to thecommission owner.

This Electronic Funds Deposit is for:

Individual/Business Name (please print) ______________________________________________ Name Associated with SSN or Tax ID

Signature X______________________________________________________________________                                                      Authorized signature as shown on the account

Social Security Number or Tax ID _____________________________________________________

Production Number ________________________________________________________________

Telephone Number (                  ) ______________________________________________________

Deposit Type: New Deposit Account or Change to Existing Deposit Account

Name of Financial Institution _________________________________________________________

Bank Routing Number ______________________________________________________________

Bank Account Number ______________________________________________________________

Account Type:    Checking Account                    or       Savings Account

               Business                                     or       Individual

A VOIDED IMPRINTED CHECK, SAVINGS DEPOSIT SLIP OR LETTER FROM THE BANKMUST BE ATTACHED TO VERIFY ACCOUNT AND ROUTING NUMBERS.

For Direct Deposit Setup Inquiries: For Compensation Inquiries:Phone: (866) 238-7179 Phone: (800) 475-4465Fax: (402) 997-1832Email: columbianmutual@medsuppservices.com

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