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AGENT'S DECLARATION AND AUTHORIZATION

1. It is agreed that throughout this document, the use of "I" references the undersigned Agent. It is further understood and agreed that I, not Partners Advantage, will be responsible to the insurance company for any commission chargebacks incurred. I also agree that Partners Advantage shall be entitled to offset any chargeback of commissions owed by me, or by a subagent under me, against any commissions which I have earned from any insurance carrier. In such event, I agree that payment of commissions to me less any such chargebacks owed by me (or my subagent) shall constitute full payment of my commissions from Partners Advantage. I also agree that I will be responsible for any debt that is rolled up to Partners Advantage from any insurance carrier with whom I have an outstanding debt. I also agree that Partners Advantage may send me to collections if any debt is not paid in full, and I agree to cooperate with the collections agency.

2. I fully understand and agree that I am not an employee, agent, representative, or independent contractor of Partners Advantage, and accordingly, that I am not authorized to so represent myself, nor will I hold Partners Advantage responsible for my actions. Both Partners Advantage and I may terminate this relationship at any time, for any reason, with or without cause, by delivering at least one (1) business day notice of such termination to the other.

3. I hereby agree to indemnify, defend and hold harmless Partners Advantage, as well as its owners, members, officers, directors, agents, employees, and representatives, from any claims or liabilities which may arise in any manner from my conduct and actions (or failures to act) as a licensed insurance agent, as well as from any claims or liabilities which may arise in any manner from my carrying out the authority granted under usage of signature (for any online contract) for the sole purposes of obtaining carrier appointment. The duty to defend includes any attorney's fees and costs incurred by Partners Advantage as a result of any such claim or liability.

4. I am fully aware and agree that as a licensed insurance agent it is my responsibility to completely understand the products and companies I represent and to conduct my business in compliance with the laws and rules, including properly soliciting these products to consumers pursuant to state law within the state(s) where I hold a resident and/or non-resident license.

5. I hereby authorize any individual or company to provide Partners Advantage any and all information with reference to my character, credits, debts owed insurance companies, business reputation and employment history, and I release said individual and/or company from any and all liability which results, or might result, from the disclosure of such information.

6. I understand that by providing my fax number, e-mail address, mail address, and telephone number, in this Declaration and Authorization, I am giving express permission to the receipt of advertisements and other communications by fax, e-mail, mail, and telephone from or on behalf of Partners Advantage and its affiliates.

7. I understand that Partners Advantage is a California limited liability company, and accordingly agree that my contract application and this Declaration and Authorization shall be governed by, and construed in accordance with, the laws of the State of California without reference to its choice of law rules. I hereby irrevocably consent to personal jurisdiction and venue in the state and federal courts located in Riverside, California with respect to any actions, claims, or proceedings arising out of or in connection with this Declaration and Authorization. Notwithstanding the foregoing, I expressly acknowledge and agree that any claim or controversy arising out of or relating to this Declaration and Authorization shall be settled by arbitration conducted in Riverside, California in accordance with the Commercial Arbitration Rules of the American Arbitration Association, and judgment on the award rendered by the arbitrator may be entered in any court in Riverside, California, and the foregoing sentence regarding jurisdiction and venue in the state and federal courts located in Riverside, California shall apply only with respect to judgment on the arbitrator’s award, and enforcement of same, if necessary. I agree that either party which prevails shall be entitled to an award of attorney’s and mediator’s fees against the non-prevailing party.

8. Under penalties of perjury, I certify that all answers to the contract application and the social security number (or taxpayer identification number) shown on my application form are true and correct. I have read the above language in this Declaration and Authorization, and by signing below, I am agreeing to abide by all of the terms set forth herein.