Tit. 20, div. 700, ch. 1, exh. A CSR

Current through Register Vol. 49, No. 21, November 1, 2024.

Exhibit A - Missouri Producer Service Agreement

1. The undersigned insured hereby engages the services of _______________, a licensed Missouri insurance producer, license

# ___________, for the purpose of securing, negotiating and procuring the placement of the following described insurance coverages and to assist the undersigned in the preparation of any and all applications, underwriting data, and other information required by an insurer for the purposes of issuing an insurance policy within this state. The insurance coverage requested is: (Here describe in detail the coverage to be effected.)

2. The undersigned insured authorizes the insurance producer to commit to a maximum premium of not more than ____________

______________ for the above-stated coverage(s). (If multiple contracts of insurance are to be procured for the same insured or prospectiveinsured, a separate maximum may be stated for each contract covered by this agreement.)

The undersigned insured agrees to pay as compensation to the insurance producer, above and in addition to the commission received from the insurer, for the various services of the insurance producer a fee of not more than $ ________________________ . (If multiple contracts ofinsurance are to be procured for the same insured or prospective insured, a separate producer fee may be stated for each contract covered by this agreement.)

3. A brief description of those services performed and not described in paragraph 1. above is: _____________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

This agreement is in furtherance of section 375.116, RSMo, and Regulation 20 CSR 700-1.100.

Dated: ______________________________________________________________________________________________________________

(Insured)

Dated: ______________________________________________________________________________________________________________

(Insurance Producer)

Tit. 20, div. 700, ch. 1, exh. A CSR

AUTHORITY: section 374.045, RSMo 2000 and sections 375.071-375.136, RSMo Supp. 2007.* This rule was previously filed as 4 CSR 190-12.080. Original rule filed Dec. 23, 1975, effective Jan. 2, 1976. Amended: Filed Oct. 14, 1981, effective Jan. 15, 1982. Amended: Filed Jan. 17, 1986, effective June 28, 1986. Amended: Filed Oct. 15, 1996, effective May 30, 1997. Amended: Filed April 12, 1999, effective Nov. 30, 1999. Amended: Filed July 12, 2002, effective Feb. 28, 2003. Amended: Filed Nov. 30, 2007, effective July 30, 2008.

*Original authority: 374.045, RSMo 1967, amended 1993, 1995 and 375.071-375.136, see Revised Statutes of the State of Missouri, 2000 and Cumulative Supplement, 2007.