AGENT OF RECORD APPOINTMENT

DATE:___________

This is to verify that RICHARD F. VIEHDORFER is the Agent of Record/Consultant for:

__________________________________________________________(employer)

on employee group health and other related benefits, effective ____ / ____ / _____.

This Agent of Record/Consultant will be effective for ninety (90) days from date above, unless extended by mutual agreement of the parties.

It is the prerogative of the employer named above to terminate this agreement at any time, with ten days written notice.

This Agent of Record/Consultant will be performing advisory services in exchange for fees or commissions in-force at the time of the account sale.

authorized signature:________________________________________

title:______________________________date:___________________

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