Compensation disclosure form

Our optional compensation disclosure form (PDF, 53KB) can help you keep compliant records. If you decide to use our form, remember:

If the only compensation you receive is a commission from an insurer, there is no need to complete a compensation disclosure form.

  • If the only compensation you receive is from the fee being charged (you do not receive any commission), you need only complete Part 1 of the form.
  • If you charge a fee and receive a commission from an insurer, you need to complete Parts 1 and 2 of the form. If you will offset some or all of the fee, provide an explanation of how the offset works under Part 2.
  • If you charge a fee, receive an initial commission and could possibly receive contingent commissions in the form of awards, bonuses, etc., you need to complete Parts 1, 2 and 3 of the form.
  • Always make sure both the writing producer and the insured/client sign and date the form. The completed form should be retained by the writing producer for five years.

Updated 03/27/2014

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