asurion service provider – retail business profile · 2016-02-26 · asurion proprietary and...

Asurion Service Provider – Retail Business Profile

Date:

Company Name:

Doing Business As: Type of Business (Select One):

_Corporation• _ Partnership _ Sole Proprietorship _ Limited Liability Corporation

Physical Address of Repair Facility: ________________________________________________________

• City: State: Zip Code:

Billing Address: ___________________________________________________________________________________

• City: State: Zip Code:

Main Telephone Number (Include Area Code):

Emergency Telephone Number (Include Area Code):

Email Address:

Fax Number (Include Area Code):

Preferred Method of Contact: _ Email Notification _ Fax Notification _ On-Line Scheduling

Contact Person:

Service Manager / Owner:

Professional Association Memberships (Ex: NESDA, PSA, USA): _______________________________________ Are you related to any retailer? _ Yes _ No

Do you sell Asurion extended service plans? _ Yes _ No

• What is the name of the program?

• What is the dealer number?

Are you a DTV Licensed Service Provider? _ Yes _ No

• What is your Corporate ID? ______________________________________________________________

• What is your Dealer Number? _____________________________________________________________ Type of service provided:

_ In-Home _ Carry-In _ Pickup/Delivery _ Depot/Mail-In

Additional locations? _ Yes _No

Physical address of repair facility: ___________________________________________________________

• City: State: ZIP Code:

Main Telephone Number (Include Area Code):

Emergency Telephone Number (Include Area Code):

Email Address:

Fax Number (Include Area Code):

Is the billing location the same as the main location? _ Yes _ No

Service Referral Information

• Please note that repair requests are assigned based on the information provided below. Incorrect or incomplete information may prevent you from receiving referrals from Asurion.

Primary Coverage Area

(The area you are willing to service on a regular basis)

ZIP Code coverage

_______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______

Secondary Coverage Area (The area you are willing to service for an additional fee)

ZIP Code coverage _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ ________ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ ________

Radius/Drive Time: Miles/Min Radius/Drive Time: Miles/Min

Directions: Please email your completed business profile, along with the other documents in your Asurion binder, to: [email protected]. Thank you!

mailto:[email protected]

Asurion Proprietary and Confidential Document Page 1 of 13

This Authorized Servicer Agreement (this “Agreement”)

is entered into by and between

Asurion Services, LLC (formerly known as National Electronics Warranty, LLC)

of 22894 Pacific Boulevard

Sterling, VA 20166

on behalf of itself and for the benefit of its affiliates, subsidiaries and parent companies

(collectively, “Asurion”),

and

__________________________________________________

of ____________________________________________

_______________________________________________

(“Servicer”)

(Asurion and Servicer individually a “Party” and together the “Parties”).

WHEREAS, Asurion is a professional administrator and marketer of service contracts and other

programs relating to products sold to customers of retail dealers, financial institutions, manufacturers and

others;

WHEREAS, Asurion desires to appoint Servicer as a non-exclusive, authorized service center

respecting the service contract and other programs which it markets and administers; and

WHEREAS, Servicer desires to accept such appointment and authorization and to perform repair

and, where applicable, maintenance services for such programs.

NOW THEREFORE, in consideration of the mutual covenants contained herein, the Parties

agree as follows:

I. DEFINITIONS

A. “Authorized User” shall have the meaning ascribed to in Section III (L).

B. “Customer” shall mean a customer of a retail dealer, financial institution, manufacturer or others, who

is referred to Servicer by Asurion for any Services.

C. “Programs” shall mean service contract and other programs administered by Asurion that cover

breakdowns of covered products from mechanical or electrical failures caused by defects in

workmanship and/or materials, and, where authorized, provide maintenance.

D. “Services” shall mean any product repair, maintenance service, and/or pickup and delivery services

performed by Servicer in connection with this Agreement or pursuant to any Programs.

II. APPOINTMENT & ASURION OBLIGATIONS

A. Subject to the terms and conditions of this Agreement and any Addendum executed pursuant to this

Agreement, Asurion hereby appoints and authorizes, on a non-exclusive basis, Servicer as an

authorized servicer of Asurion and shall include Servicer as an authorized service center under its

Programs.

B. Asurion shall refer Customers to Servicer on a non-exclusive basis to provide Services, as determined

by Asurion in its sole discretion.

C. Asurion shall evaluate claims made by Customers and repairs made or to be made by Servicer in

accordance with the terms and conditions of the Programs, attendant service contracts and Asurion’s

policies. Asurion shall have the right to accept, reject, or adjust such claims, in its sole discretion.

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D. Asurion shall promptly pay Servicer in accordance with Section IV of this Agreement for Services

performed by Servicer which have been properly documented by Servicer and properly authorized by

Asurion, as described below.

III. SERVICER OBLIGATIONS

A. Servicer shall use due care, be courteous, friendly and professional when providing the Services to

Customers referred to Servicer by Asurion, and shall maintain a clean and orderly facility for any

carry-in service provided to Customers. Servicer shall return repaired product to Customer properly

packaged and in clean condition. Servicer shall protect and maintain Customers’ property when

providing in-home service, and shall assume liability for any damage to product or property when

performing in-home service pursuant to this Agreement. Servicer shall generally promote Asurion

and its Programs and shall give priority to Asurion Customers.

B. Servicer shall perform all Services in compliance with Exhibit A, Customer Service Standards, all

Asurion procedures, specifications supplied by Asurion, all applicable federal, state and other laws,

rules and regulations, all generally accepted industry safety guidelines (including, without limitation,

any applicable product safety guidelines developed by Underwriters Laboratories and OSHA

regulations) relating to the Programs and the Services to be performed by Servicer, and any and all

amendments, changes or supplements to any of the foregoing. Servicer acknowledges that Asurion

may amend, change or supplement any of such procedures at any time and from time-to time, and that

procedures for certain Programs may override or supplement the terms of this Agreement.

C. In providing the Services, Servicer warrants that it will meet or otherwise satisfy the applicable

service levels or key performance indicators (KPIs), with respect to each of the categories set forth in

Exhibit B. The applicable KPI levels/metrics for each category shall be provided to Servicer by

Asurion and shall be determined by Asurion based on any client-specific requirements and selected

market and industry averages. If Servicer fails to achieve the agreed KPIs at any time, Asurion may,

at its sole discretion, disqualify Servicer from providing further Services and/or terminate this

Agreement immediately.

D. Servicer shall complete background checks on all employees, Authorized Users (as defined in Section

L), or any other personnel prior to assigning such persons to perform the Services. Such background

checks shall include, to the extent permitted by law, verification of the legal right to work in the

jurisdiction where the Services will be performed, criminal history checking, drug testing and any

additional testing that may be required by Asurion to meet Client specifications. The following shall

apply with respect to background checks:

1) The criminal history check shall consist, at a minimum, of a federal and state check for felony

and misdemeanor criminal convictions (or the equivalent thereof under relevant non-US law) in

all locations where the person has resided in the immediately preceding seven (7) years or such

other period as may be allowed by applicable law(s) and shall include a check of U.S.

Government Specially Designated National and the export denial lists. The criminal history check

shall also include, to the extent available, a check for outstanding warrants and a check for

pending felony charges in all such locations. Statewide county searches shall be performed in all

states where such search mechanism is available without requiring specialized data (such as

fingerprints or DNA), and the National Criminal File database shall also be searched.

2) Drug testing shall consist of a nine-panel urine analysis drug screen used to test for the presence

of marijuana, cocaine, amphetamines, PCP, opiates/metabolites, barbiturates, benzodiazepines,

propoxyphene, methadone and methaqualone. All specimens shall be tested at Department of

Health and Human Services (DHHS)/Substance Abuse Mental Health Services Administration

(SAMHSA)-certified labs, and the screening service shall include confirmation of all positive test

results. Servicer shall complete drug screening on all Authorized Users every two years during

the term of this Agreement. If the Servicer fails to complete the drug screening on each

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Authorized User every two years, Asurion may, at its sole discretion, disqualify Servicer from

providing further Services and/or terminate this Agreement immediately.

3) The name to which the person’s Social Security Number is attributed shall be verified. The

person’s citizenship, most recent country of permanent residence, and legal right to work in the

jurisdiction in which the person will be performing the Services shall be verified.

4) Servicer represents and warrants that it will not assign any employee, Authorized User, or any

other personnel to perform Services under this Agreement (including, but not limited to,

interacting with a Customer or being provided access to Customer information) if such person (a)

does not have the legal right to work in the jurisdiction in which such person will be performing

the Services; (b) has been convicted of a Disqualifying Conviction (defined as (i) any felony or

misdemeanor conviction with a disposition date of seven (7) years or less (excluding

misdemeanor traffic violations); or (ii) any felony or misdemeanor conviction, regardless of date

of disposition, that involves a violent crime, nonconsensual sexual crime, crime against children,

theft, embezzlement, fraud or dishonesty); (c) is on a U.S. Government Specially Designated

National or export denial list; or (d) has a confirmed positive test result in the drug screening

required hereunder.

E. Servicer shall use its best efforts to keep apprised of new technology relating to the Services to be

performed by Servicer, and shall maintain an adequate parts and supplies inventory for the products

to be serviced by Servicer.

F. Servicer represents and warrants that the Servicer Profile created in ServiceBench, and incorporated

herein, has been completed accurately and executed by Servicer. Servicer shall update the Servicer

Profile within thirty (30) days of any change to the information contained in the Servicer Profile.

G. Servicer unconditionally guarantees the Services to be performed by Servicer under this Agreement

for a period of no less than ninety (90) days respecting labor and parts. If within that period, there is

an actual or alleged defect in workmanship or materials, Servicer shall remedy said defect within

three (3) business days after notice by Asurion In the event a defective part is procured through the

use of the Smart Procurement Portal, the part will be replaced through normal Asurion procedures. In

the event Servicer procures parts outside the Smart Procurement Portal and fails to remedy said

defect, Asurion shall have the right in its sole discretion to have the defect corrected, or effect an

adjustment with Customer, at Servicer’s expense. Asurion may withhold and use any monies then or

thereafter due to Servicer as reimbursement or credit for the cost of having the correction made or of

the adjustment. All labor and replacement parts provided by Servicer shall be merchantable, fit for

their particular purpose, free of defects in material and workmanship, and consistent with the

recommendations of the manufacturer, general industry standards and requirements of federal, state

and local government.

H. Servicer shall be solely liable for any and all Services performed or to be performed by it pursuant to

this Agreement, and all risks pertaining to the casualty loss of products delivered to Servicer for

repair under the Programs. Servicer shall indemnify, defend and hold harmless Asurion and its

officers, directors, employees, affiliates and clients from and against any and all claims, costs,

damages, expenses and liabilities, including attorneys’ fees and expenses, resulting from or relating to

Servicer’s performance of or failure to perform its obligations under this Agreement. This

indemnification obligation shall survive the termination of this Agreement and will not be limited by

any insurance policy or policies obtained or required to be maintained. Servicer shall at all times

during the term of this Agreement maintain not less than the minimum insurance coverage levels

outlined in Exhibit C with financially reputable insurers who are licensed to do business in the

jurisdiction(s) where the Services are performed and who are reasonably acceptable to Asurion

I. Servicer shall not perform any Services under this Agreement, or otherwise, on behalf of Asurion

without prior authorization in the form of a system-generated electronic format (hand written referrals

shall not comprise prior authorization) from Asurion All such authorizations shall be granted by

Asurion in its sole discretion.

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J. Servicer shall dispose of or recycle all defective parts and components removed from a product

serviced by Servicer pursuant to this Agreement in compliance with all applicable regulations, rules

or laws, unless Asurion instructs Servicer in writing that a third party shall conduct such disposal, in

which case the Servicer shall provide the parts for disposal in accordance with Asurion’s instructions.

K. Servicer shall perform all Services in accordance with the performance standards and procedures

outlined in Exhibit D.

L. For any and all subcontractors, consultants or other service providers who, by virtue of such

individual or entity’s relationship to, or permissions from, Servicer, may be authorized to provide any

of the Services under this Agreement or to access any ServiceBench portals or other database or

software, including but not limited to the Smart Procurement Portal, pursuant to Servicer’s rights

under this Agreement (an “Authorized User”):

1. Servicer shall submit written notice in ServiceBench of the name, address and relationship to

Servicer of all such Authorized Users prior to granting such Authorized Users access to any

ServiceBench portals, database or software;

2. Servicer shall ensure that all Authorized Users will be bound by a contractual, enforceable

agreement, which agreement, will, by its terms, provide substantially the same or greater

protections for Asurion’s Confidential Information; and

3. Servicer shall ensure that all Authorized Users satisfy the background check requirements set

forth in Section III (D).

4. Servicer shall be solely responsible for all acts or omissions of the Authorized Users in

connection with the Services and shall indemnify, defend and hold harmless Asurion and its

officers, directors, employees, affiliates and clients from and against any and all claims, losses,

damages, liabilities, fines, taxes, costs and expenses, including attorney’s fees and other legal

expenses, arising directly or indirectly from (i) any negligent, reckless or intentionally wrongful

act of the Authorized User or (ii) any breach by an Authorized User or of any of the covenants

contained in this Agreement.

5. Asurion may, at its option, instruct Servicer to discontinue the use of an Authorized User. In such

event, Servicer shall immediately comply with Asurion’s instruction and shall ensure that such

Authorized User no longer has access to any ServiceBench portals or other database or software.

IV. PAYMENT

A. Asurion shall arrange for payment to be made to Servicer for all Services authorized by Asurion and

performed by Servicer in accordance with the terms and conditions of this Agreement. All payment

will be made in U.S. Dollars.

B. All claims shall be submitted to Asurion by Servicer through the claims module in ServiceBench.

Servicer shall not employ any alternative means to submit claims to Asurion without the prior

approval of Asurion, in its sole discretion.

C. A Servicer may employ the services of a third party to submit claims on a Servicer’s behalf; however

the Servicer is solely responsible for the payment of any third party’s fees for services and must

ensure that the third party is an Authorized User as defined above. Asurion does not pay for or

reimburse a Servicer for administrative fees relating to the filing of claims, whether those

administrative fees are incurred by a Servicer in-house or charged by a third party. By signing this

Agreement, the Servicer agrees that no claim submitted to Asurion includes a charge for any

administrative fees and that the claims submitted accurately reflect the applicable charges associated

with the Services.

D. All initial claims or resubmitted claims for completed Services shall be submitted to Asurion for

payment within thirty (30) days of the repair completion date. Claims submitted more than ninety

(90) days from the date the Customer reports a product failure shall be rejected, unless prior written

approval is obtained from Asurion, in its sole discretion.

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E. If Servicer provides diagnostic services (either in-home or in-shop) and determines that a product has

not experienced a mechanical or electrical failure caused by defects in workmanship and/or materials

(a “non-warranty failure”), Servicer shall contact Asurion immediately and report such non-warranty

failure. If Servicer follows such procedures, Servicer shall be entitled to payment for such diagnostic

services from Customer or, if authorized by Asurion, from Asurion

F. Right of Offset. Asurion reserves the right to offset any amounts otherwise due to Servicer from

Asurion or its affiliates against amounts owed by Servicer to Asurion or its affiliates in respect of any

Unreturned Cores or other amounts due under this Agreement.

V. MISCELLANEOUS

A. Term. The term of this Agreement will commence on the date hereof and will end on the date

specified in a written notice provided by one Party to the other Party at least thirty (30) days prior to

such termination date. Notwithstanding the aforementioned, this Agreement may be terminated:

1. By either Party in the event that the other Party fails to pay any amount when due under the terms

of this Agreement or fails to observe or perform any material agreement of the latter Party in this

Agreement, and any such failure continues for a period of ten (10) days after written notice of

such failure has been provided by the former Party to the latter Party; or

2. By either Party immediately if a case is commenced by or against the other Party seeking

liquidation, reorganization or other relief with respect to the latter Party or its debts, or seeking

the appointment of a trustee, receiver, liquidator, custodian, conservator or similar official for the

latter Party or any substantial part of its property, or the latter Party makes a general assignment

for the benefit of creditors.

Termination of this Agreement shall have no effect on services being performed by Servicer and

authorized by Asurion, or payments owed by Asurion to Servicer at the time of such termination.

B. Governing Law. This Agreement and the legal relations between the Parties shall be governed by and

construed in accordance with the laws of the Commonwealth of Virginia, without giving effect to the

principles of conflicts of law.

C. Entire Agreement. This Agreement supersedes any other agreement, written or oral, that may have

been made or entered into by the Parties hereto relating to the matters contemplated hereby. This

Agreement constitutes the entire agreement by and among the Parties with respect to the subject

matter hereto and there are no other agreements or commitments except as expressly set forth herein.

D. Amendment & Waiver. This Agreement may be amended or supplemented at any time only by

additional written agreements executed by the Parties. No waiver of this Agreement or any covenant,

condition or limitation contained herein shall be valid unless agreed to in writing by the Parties.

E. Notice. Any formal notice or communication required or permitted under this Agreement shall be in

writing and shall be deemed to have been duly provided if delivered by hand delivery, by certified or

registered first class mail, postage prepaid, return receipt requested, by recognized overnight courier

service, or by facsimile or other means of electronic transmission (with reasonable evidence of

receipt) addressed as follows:

If to Servicer, then at the address reflected in the Servicer Profile.

If to Asurion:

Asurion Services, LLC

22894 Pacific Boulevard

Sterling, VA 20166

Attention: Service Management

Fax: 571-262-7323

With a copy to:

Asurion Services, LLC

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ATTN: General Counsel’s Office

648 Grassmere Park

Nashville, TN 37211

F. Other communications. Asurion may, from time to time, through itself or through a third party

vendor, provide Servicer with periodic bulletins and or service updates via email to the email address

specified by Servicer in Servicer’s ServiceBench profile. Servicer hereby agrees and consents to

receive such emails, whether from Asurion or a third party vendor of Asurion, provided that Servicer

may opt-out of such emails by submitting a request to unsubscribe to Asurion

G. Successors; Assigns. This Agreement shall be binding upon and shall inure to the benefit of each

Party and its respective successors and permitted assigns. Except as expressly stated herein, this

Agreement shall not be assignable or delegable in whole or in part by Servicer without the prior

written consent of Asurion

H. Relationship of Parties. In the exercise of its rights and the performance of its obligations hereunder,

each Party shall act solely as an independent contractor, and nothing contained herein shall be

construed to create a relationship of agency, partnership or joint venture between the Parties. Each of

the Parties covenants and agrees that it shall not have or hold itself out as having any right, authority

or agency to act on behalf of the other Party in any capacity or in any matter except as specifically

authorized in this Agreement, and none of the Parties shall become liable to any person by reason of

any representation, action or omission contrary to this provision. Servicer acknowledges and agrees

that Servicer is obligated to report as income all compensation received by Servicer pursuant to this

Agreement, and that Servicer is obligated to pay any applicable state and/or federal taxes and

obligations on said income.

I. Confidentiality. Servicer agrees that the terms of this Agreement and all information relating to this

Agreement and the business of Asurion and/or its Customers are confidential and proprietary.

“Confidential Information” means any proprietary information, technical data, trade secrets or know-

how, including, but not limited to, research, product plans, products, services, customer data,

customer lists, markets, software, developments, inventions, processes, formulas, technology,

designs, drawings, engineering, hardware configuration information, marketing, finances or other

business information of either party disclosed by one party (the “Disclosing Party”) to the other party

(the “Receiving Party”) either directly or indirectly in writing, orally or by drawings or inspection of

parts or equipment and regardless of whether marked as such. Confidential Information shall also

include Customer Data, which is defined as any information pertaining to individuals, whether

employees or Customers of Asurion or its clients, including but not limited to; Home and Business

Addresses and Phone Numbers, credit card information, and any other personally identifiable

information obtained by Servicer, in any form, in the course of providing the Services. In respect of

the Confidential Information, the Parties agree as follows:

1. The Receiving Party shall not, during or subsequent to the term of this Agreement, use the

Disclosing Party’s Confidential Information for any purpose whatsoever other than the

performance of Services on behalf of Asurion or disclose the Disclosing Party’s Confidential

Information to any third party. It is understood that said Confidential Information will remain the

sole property of the Disclosing Party. The Receiving Party shall take all reasonable precautions

to prevent any unauthorized disclosure of such Confidential Information including, but not

limited to, having each employee of the Receiving Party, if any, with access to any Confidential

Information, execute a nondisclosure agreement containing provisions in the Disclosing Party’s

favor. Confidential Information does not include information which (i) is known to the Receiving

Party at the time of disclosure to the Receiving Party by the Disclosing Party as evidenced by

written records of the Receiving Party, (ii) has become publicly known and made generally

available through no wrongful act of the Receiving Party, or (iii) has been rightfully received by

the Receiving Party from a third party who is authorized to make such disclosure.

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2. Servicer recognizes that Asurion has received and in the future will receive from third parties

their confidential or proprietary information subject to a duty on Asurion’s part to maintain the

confidentiality of such information and to use it only for certain limited purposes. Servicer agrees

that Servicer owes Asurion and such third parties, during the term of this Agreement and

thereafter, a duty to hold all such confidential or proprietary information in the strictest

confidence and not to disclose it to any person, firm or corporation or to use it except as

necessary in carrying out the Services for Asurion consistent with Asurion’s agreement with such

third party.

3. In the event that the Receiving Party or its respective directors, officers, employees, consultants

or agents are requested or required by legal process to disclose any of the Confidential

Information of the Disclosing Party, the Receiving Party shall give prompt advance notice so that

the Disclosing Party may seek a protective order or other appropriate relief. In the event that such

protective order is not obtained, the Receiving Party shall disclose only that portion of the

Confidential Information which its counsel advises that it is legally required to disclose, provided

that the Receiving Party shall exercise its reasonable efforts to preserve confidentiality of the

Confidential Information including, without limitation, by cooperating with the Disclosing Party

to obtain an appropriate order or other reliable assurance that confidential treatment will be

accorded the Confidential Information by such tribunal.

4. Customer Data must be maintained in a secure environment that meets industry standards (i.e.

stored and transmitted in encrypted or otherwise secure form). In the event of a breach of

security of any system, website, database, equipment or storage medium or facility that results in

unauthorized access to Customer Data, Servicer must report such incident to Asurion

immediately and make best efforts to re-secure the systems immediately.

5. Upon the termination of this Agreement, or upon the Disclosing Party’s earlier request, the

Receiving Party shall deliver to the Disclosing Party all of the Disclosing Party’s property or

Confidential Information that the Receiving Party may have in the Receiving Party’s possession

or control.

J. Audit. Asurion shall have the right, at its sole discretion, to inspect, examine or audit Servicer’s

background screening and drug testing process, books and records pertaining to the Services, cores or

parts ordered through ServiceBench, any amounts exchanged under this Agreement or any other

business related to this Agreement (including, but not limited to, a physical audit of Servicer’s

facility(ies) and any consigned inventory at the Servicer’s location), which examination shall be

performed during normal business hours and upon reasonable prior notice to Servicer.

By clicking the “Accept” button, You are consenting to be bound by and

are becoming a party to this Agreement. If You do not agree with the

terms of this Agreement, do not click the “Accept” button.

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Exhibit A

Customer Service Standards

Servicer shall adhere to the following customer service standards which may amended by Asurion from

time to time by providing Servicer with written notice fourteen (14) days prior to the date of expected

compliance:

1. Servicer must contact the Customer within one (1) business day before the scheduled dispatch to

introduce him/herself, confirm the service to be performed and confirm approximate arrival

window.

2. Servicer shall ensure that each appointment is started within the scheduled time frame, as

guaranteed to the Customer.

3. If for any reason the Servicer will not be able to make it to the Customer’s location or cannot

perform the installation/service as scheduled; a representative from Asurion must be notified

immediately.

4. Asurion must be notified, via ServiceBench update, of any rescheduled appointment.

5. Servicer shall call Customer 30 minutes prior to expected arrival time.

6. Upon arrival at Customer residence, Servicer will notify Asurion of arrival via IVR call, status

update via mobile application, or other technology that would update ServiceBench.

7. Whenever reasonably possible and safe, Servicer shall avoid parking in Customer’s driveway or

blocking ingress/egress, except when necessary to unload tools or products.

8. In no event shall Servicer enter a Customer residence unless an adult, age 18 or older, is present;

nor shall Servicer permit any work order to be signed by anyone who is not at least age

18..Services can only be performed if authorized by an adult (at least 18 years old) who has the

authority to authorize changes in the scope of work to be completed.

9. Servicer will wait a minimum of 15 minutes before determining a Customer “no show” has

occurred.

10. If Servicer leaves location before Customer’s arrival, Servicer shall leave door tag with time

arrived and contact information for rescheduling.

11. Servicer will conduct a pre-service consultation with Customer at the start of the appointment to

ensure that Customer understands the service to be performed and to ensure all Customer

requirements have been met.

12. As applicable, drop cloths or protective materials shall be used to cover floors and furniture

during services. All tools shall be placed on tool cloths. All exposed furniture that might be

affected by debris from the services should be covered.

13. In the event a part needs to be ordered and reinstalled at a subsequent date to the original service

call, the new part installation should occur within 48 hours of the receipt of the part.

14. Servicer should avoid using Customer's bathroom. If necessary, ask for permission.

15. Servicer should never borrow Customer's tools, ladders or vacuum.

16. Servicer shall never use foul language or profanity.

17. Servicer must not smoke, chew, accept food and/or beverages even if offered by the Customer.

18. Servicer must report any damage to Customer’s home or property to Asurion immediately upon

the occurrence of such damage.

19. Upon completion of the services, Servicer shall remove all trash from and about the area, remove

all of their tools, equipment and materials and leave the work area "clean" and ready for use.

20. Servicer shall clean all products that were installed or serviced.

21. When installation/service is complete, Servicer shall explain the installation/service to Customer

and make sure Customer is completely satisfied.

22. Servicer shall perform a thorough demonstration of the installation/services and validate that

Customer completely understands how to use all aspects of their equipment.

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23. Servicer shall ask Customer for permission prior to taking any digital photographs, if needed.

24. Servicer shall let Customer know that they may be contacted/surveyed by a Asurion

representative.

25. Servicer shall never solicit Customer for additional business for Servicer or others while

performing services for Asurion.

26. Servicer shall never disparage Asurion, our clients, customers, any products/services or the

competition.

27. Upon departure of customer residence, Servicer will notify Asurion of departure via IVR call,

status update via mobile application, or other technology that would update ServiceBench.

28. Servicer must use current mobile technology and/or Business Management System with API to

ServiceBench to enable statusing of all work orders in real time and at minimum within 24 hours

of the service event. 29. Servicer must maintain all certifications that Asurion may require to perform service.

30. All Servicers must be branded to Asurion standards at all times when on Asurion business.

31. Dress and Vehicle standards must be maintained as per below:

Dress Standards

o Shirt/Blouse: This article of clothing shall be: (a) clean; (b) free of any advertising

logo or message except for that of the retail partner that has assigned the work to

Servicer; and (c) free of holes or tears.

o Pants/Shorts: This article of clothing shall be: (a) clean; (b) free of any advertising

logo or message except for that of the retail partner that has assigned the work to Servicer

or that of the clothing manufacturer; and (c) free of holes and tears. Shorts shall not be

worn unless approved by the retail partner that has assigned the work.

o Hat/Cap: If required, this article of clothing shall be free of any advertising logo or

message other than that of the retail partner that has assigned the work to Servicer.

o Footwear: This article of clothing shall be compliant to OSHA safety regulations.

Shoes and boots shall be clean and free of holes and tears, and shall be worn at all times.

o Booties: Protective shoe covers or booties shall be worn inside a customer’s home

or office in order to prevent staining of flooring materials. Booties shall not be worn on

ladders due to safety regulations.

o Jewelry: Any jewelry worn by Servicer shall be compliant to OSHA regulations.

o Tattoos: Tattoos that are offensive or distractive shall be covered at all times.

Vehicle Standards

o Late model vehicle, van, suv, cross-over or pickup truck less than 10 years old.

o Vehicle should be clean (exterior and bed) and in good repair (not leaking oil, etc.).

o Vehicles should be monochromatic and free of offensive decals and/or stickers.

o If vehicle is a pickup truck and is used to deliver products, it must be equipped with a

cap or cover.

o Canvas or plastic tarps are not acceptable methods for covering or protecting products

and therefore not approved.

10/22/2014


Exhibit B

Measured KPI’s & Definitions

1. Tech In and Tech Out Compliance – The percentage of the total dispatches where the

Service center has provided a Technician arrival and Technician departure on a service

event.

2. Tech In Service Window Compliance – The percentage of dispatches where the Technician

Arrival Time is within the customer’s promised service window.

3. Customer Turn Time – The time frame in which it takes a customer to have their

service issue resolved. (Customer Call In Date to Service Complete Date).

4. First Trip Complete (FTC) – The percentage of total completed dispatches where the dispatch

is completed on the first visit to customers home. (Repair Started date to Repair Complete date)

5. No Call No Show (NCNS) – The percentage of dispatches where the customer has advise the

technician did not show up on the day and in service window promised. Documented customer

NCNS will not be included.

6. Buyout Rate – The percentage of completed service calls that turn into a customer replacement.

10/22/2014


Exhibit C

Insurance Requirements

Servicer shall at all times maintain not less than the following insurance coverage with financially

reputable insurers who are licensed to do business in the jurisdiction where the Services will be performed

and who are reasonably acceptable to Asurion:

1. Commercial General Liability insurance with limits of at least $1,000,000 per occurrence and in

the aggregate, including but not limited to premises-operations, products-completed operations,

contractual liability, independent contractors, and personal and advertising injury liability

hazards, naming Asurion, its officers, directors, employees and affiliates as additional insureds

and using ISO Forms CG 20 10 07 04 and CG 20 37 07 04 or equivalent forms;

2. Business Auto liability including coverage for “any auto” with limits of not less than $250,000

combined single limit per accident for bodily injury and property damage (or not less than

$100,000 per person, $300,000 per accident for bodily injury and $50,000 per accident for

property damage); and

3. Workers’ Compensation insurance for Servicer, and all employees, owners, partners or other

persons working for Servicer (even if not mandated by applicable laws), including Employer’s

Liability insurance.

Upon execution of this Agreement, Servicer shall deliver to Asurion or assigned agent a Certificate of

Insurance (ACORD 25 or equivalent) evidencing such insurance coverage, including copies of

amendatory endorsements extended coverage to Asurion, its officers, directors, employees and its

affiliates as additional insureds. Servicer shall require its insurer(s), by endorsement if necessary, to

provide Asurion with at least thirty (30) days advance written notice of any cancellation of Servicer’s

insurance policies. Servicer shall deliver a renewal certificate to Asurion, prior to the expiration date of

any required insurance coverage under this Agreement.

10/22/2014


Exhibit D

Performance Standards & Procedures

1. If Servicer is assigned a service call for in-home Services (a “Call”) by Asurion, Servicer shall,

within one (1) business day of receipt of notification from Asurion of the Call, contact the

Customer during regular business hours to schedule the Call or verify the scheduled time for the

Call.

2. Servicer shall be notified by Asurion if Customer changes the Call date and/or time or cancels the

Call. Servicer shall use its best efforts to accommodate any rescheduled Call; however, if Servicer

cannot accommodate such rescheduled Call, Servicer will contact Customer and reschedule the

Call and shall provide Asurion with prompt notice of such rescheduled Call. If Servicer is unable

to accommodate the Customer, Servicer shall contact Asurion and Asurion shall have the right, in

its sole discretion, to reassign the Call to another Servicer.

3. Prior to initiating service for any Call, Servicer shall first determine whether the Call can be

satisfactorily completed under the terms of the applicable service order. Servicer shall

immediately notify Asurion if such service cannot be completed, and the Call shall thereafter be

deemed withdrawn in the absence of Asurion providing new terms for such Call to Servicer.

4. If Asurion provides notice to the Servicer to contact a Customer concerning a Call, Servicer shall

contact the Customer within one (1) business day of receiving such notice.

5. Servicer shall furnish Asurion timely updates of the status of Calls throughout the service

process. Such updates shall include, but not be limited to, changes to Calls, progress toward

completion, and failure to complete a Call for any reason. Status updates shall be provided

through ServiceBench. If parts are required to complete service for the Call, Servicer shall

provide a rescheduled Call date and time for the Call based upon Servicer’s knowledge as to

when the parts should be received. Servicer must use current mobile technology and/or Business

Management System with API to ServiceBench to enable statusing of all work orders in real time

and at minimum within 24 hours of the service event.

6. All Services to be performed by Servicer under the Programs shall be completed by Servicer (i)

on the first Call if no parts are required or Servicer has the part needed to complete the repair

when making the Call or (ii) within five (5) days of Servicer’s receipt of the part where the part

must be ordered.

7. If parts are required to complete service for the Call, Servicer will order the part(s) through the

Smart Procurement Portal in ServiceBench, when available. Title to the part(s) and the risk of

loss for any casualty to the part(s) regardless of the cause, will transfer to the Servicer upon

receipt of the part(s).

8. If a part(s) utilized on a Call was not ordered through the Smart Procurement Portal in

ServiceBench, the markup charged by the Servicer for such part shall not exceed the lesser of ten

percent of the part cost or fifty U.S. Dollars ($50.00).

9. Servicer is solely responsible for the return of any and all cores as a result of parts ordered or

procured by Servicer. All outstanding cores that are not returned within thirty (30) days of

original shipment are deemed unreturned (“Unreturned Cores”) and will be either billed directly

to Servicer or automatically debited from the Servicer’s service center account with Asurion In

10/22/2014


exchange for the appointment of the authorized Servicer hereunder and/or Servicer’s authorized

use of the Smart Procurement Portal, Servicer agrees to maintain an active credit card registered

to Servicer on file with Asurion and hereby authorizes Asurion to debit/charge the Servicer’s

credit card for Unreturned Cores.

10. All requests for additional authorizations (including trip charges, additional labor, freight, etc.),

must be submitted through the authorization module in Service Bench, and must be approved by

Asurion to be eligible for payment.

10/22/2014

Form W-9(Rev. December 2014)Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the requester. Do not send to the IRS.

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2.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶

Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.

Other (see instructions) ▶

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.)

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.

Social security number

– –

orEmployer identification number

–

Part II CertificationUnder penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

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

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.

Sign Here

Signature of U.S. person ▶ Date ▶

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9.

Purpose of FormAn individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following:

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

• Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2.

By signing the filled-out form, you:

1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and

4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information.

Cat. No. 10231X Form W-9 (Rev. 12-2014)

Form W-9 (Rev. 12-2014) Page 2

Note. If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:

• An individual who is a U.S. citizen or U.S. resident alien;

• A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States;

• An estate (other than a foreign estate); or

• A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.

In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States:

• In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity;

• In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and

• In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.

Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).

Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items:

1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.

2. The treaty article addressing the income.

3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions.

4. The type and amount of income that qualifies for the exemption from tax.

5. Sufficient facts to justify the exemption from tax under the terms of the treaty article.

Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.

If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233.

Backup WithholdingWhat is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 28% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.

Payments you receive will be subject to backup withholding if:

1. You do not furnish your TIN to the requester,

2. You do not certify your TIN when required (see the Part II instructions on page 3 for details),

3. The IRS tells the requester that you furnished an incorrect TIN,

4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or

5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See Exempt payee code on page 3 and the separate Instructions for the Requester of Form W-9 for more information.

Also see Special rules for partnerships above.

What is FATCA reporting?The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code on page 3 and the Instructions for the Requester of Form W-9 for more information.

Updating Your InformationYou must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies.

PenaltiesFailure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.

Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.

Specific InstructionsLine 1You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return.

If this Form W-9 is for a joint account, list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9.

a. Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name.

Note. ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application.

b. Sole proprietor or single-member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or “doing business as” (DBA) name on line 2.

c. Partnership, LLC that is not a single-member LLC, C Corporation, or S Corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2.

d. Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2.

e. Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a “disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, “Business name/disregarded entity name.” If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.


Line 2If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2.

Line 3Check the appropriate box in line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box in line 3.

Limited Liability Company (LLC). If the name on line 1 is an LLC treated as a partnership for U.S. federal tax purposes, check the “Limited Liability Company” box and enter “P” in the space provided. If the LLC has filed Form 8832 or 2553 to be taxed as a corporation, check the “Limited Liability Company” box and in the space provided enter “C” for C corporation or “S” for S corporation. If it is a single-member LLC that is a disregarded entity, do not check the “Limited Liability Company” box; instead check the first box in line 3 “Individual/sole proprietor or single-member LLC.”

Line 4, ExemptionsIf you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space in line 4 any code(s) that may apply to you.

Exempt payee code.• Generally, individuals (including sole proprietors) are not exempt from backup withholding.

• Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends.

• Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions.

• Corporations are not exempt from backup withholding with respect to attorneys' fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC.

The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4.

1—An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2)

2—The United States or any of its agencies or instrumentalities

3—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

4—A foreign government or any of its political subdivisions, agencies, or instrumentalities

5—A corporation

6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession

7—A futures commission merchant registered with the Commodity Futures Trading Commission

8—A real estate investment trust

9—An entity registered at all times during the tax year under the Investment Company Act of 1940

10—A common trust fund operated by a bank under section 584(a)

11—A financial institution

12—A middleman known in the investment community as a nominee or custodian

13—A trust exempt from tax under section 664 or described in section 4947

The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13.

IF the payment is for . . . THEN the payment is exempt for . . .

Interest and dividend payments All exempt payees except for 7

Broker transactions Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012.

Barter exchange transactions and patronage dividends

Exempt payees 1 through 4

Payments over $600 required to be reported and direct sales over $5,0001

Generally, exempt payees 1 through 52

Payments made in settlement of payment card or third party network transactions

Exempt payees 1 through 4

1 See Form 1099-MISC, Miscellaneous Income, and its instructions.

2 However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency.

Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with “Not Applicable” (or any similar indication) written or printed on the line for a FATCA exemption code.

A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37)

B—The United States or any of its agencies or instrumentalities

C—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i)

E—A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i)

F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state

G—A real estate investment trust

H—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940

I—A common trust fund as defined in section 584(a)

J—A bank as defined in section 581

K—A broker

L—A trust exempt from tax under section 664 or described in section 4947(a)(1)

M—A tax exempt trust under a section 403(b) plan or section 457(g) plan

Note. You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed.

Line 5Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns.

Line 6Enter your city, state, and ZIP code.

Part I. Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN.

If you are a single-member LLC that is disregarded as an entity separate from its owner (see Limited Liability Company (LLC) on this page), enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN.

Note. See the chart on page 4 for further clarification of name and TIN combinations.

How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local SSA office or get this form online at www.ssa.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/businesses and clicking on Employer Identification Number (EIN) under Starting a Business. You can get Forms W-7 and SS-4 from the IRS by visiting IRS.gov or by calling 1-800-TAX-FORM (1-800-829-3676).

If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.

Note. Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.

Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8.


Part II. CertificationTo establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if items 1, 4, or 5 below indicate otherwise.

For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exempt payees, see Exempt payee code earlier.

Signature requirements. Complete the certification as indicated in items 1 through 5 below.

1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification.

2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.

3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.

4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).

5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.

What Name and Number To Give the RequesterFor this type of account: Give name and SSN of:

1. Individual The individual2. Two or more individuals (joint

account)The actual owner of the account or, if combined funds, the first individual on the account1

3. Custodian account of a minor (Uniform Gift to Minors Act)

The minor2

4. a. The usual revocable savings trust (grantor is also trustee) b. So-called trust account that is not a legal or valid trust under state law

The grantor-trustee1

The actual owner1

5. Sole proprietorship or disregarded entity owned by an individual

The owner3

6. Grantor trust filing under Optional Form 1099 Filing Method 1 (see Regulations section 1.671-4(b)(2)(i)(A))

The grantor*

For this type of account: Give name and EIN of:

7. Disregarded entity not owned by an individual

The owner

8. A valid trust, estate, or pension trust Legal entity4

9. Corporation or LLC electing corporate status on Form 8832 or Form 2553

The corporation

10. Association, club, religious, charitable, educational, or other tax-exempt organization

The organization

11. Partnership or multi-member LLC The partnership12. A broker or registered nominee The broker or nominee

13. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments

The public entity

14. Grantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulations section 1.671-4(b)(2)(i)(B))

The trust

1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.

2 Circle the minor’s name and furnish the minor’s SSN.

3 You must show your individual name and you may also enter your business or DBA name on the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN.

4 List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships on page 2.

*Note. Grantor also must provide a Form W-9 to trustee of trust.

Note. If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

Secure Your Tax Records from Identity TheftIdentity theft occurs when someone uses your personal information such as your name, SSN, or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.

To reduce your risk:

• Protect your SSN,

• Ensure your employer is protecting your SSN, and

• Be careful when choosing a tax preparer.

If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter.

If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.

For more information, see Publication 4535, Identity Theft Prevention and Victim Assistance.

Victims of identity theft who are experiencing economic harm or a system problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059.

Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft.

The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts.

If you receive an unsolicited email claiming to be from the IRS, forward this message to [email protected]. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at: [email protected] or contact them at www.ftc.gov/idtheft or 1-877-IDTHEFT (1-877-438-4338).

Visit IRS.gov to learn more about identity theft and how to reduce your risk.

Privacy Act NoticeSection 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.

asurion service provider – retail business profile · 2016-02-26 · asurion proprietary and...

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