As indicated by the signature(s) on this form, I (we) have been advised and have full knowledge that in applying for insurance with Kamkar Insurance Agency providing Health Insurance With Maternity Coverage. I (we) are paying to Kamkar Insurance Agency (THE AGENCY) a one-time, non-refundable service charge of $ _________ Dollars. The service fee will be paid when the Insurance Company approves our application, but before the insurance proposal is delivered to us. Furthermore I (we) understand and agree that should the application for insurance be rated up, requested coverage be canceled or the application voided by the insured, the service charge is fully earned and no portion of the service charge will be refunded or returned.
I (we) further agree and understand that the payment for such service fee will be paid in advance to presentation of acceptable proposal by the Insurance Company and it is payable via bank transfer or direct deposit to agency account. I (we) understand and agree this fee is in addition to premium charged by the Insurance Company and any commission due and payable to THE AGENCY by respective Insurance Company which provides the requested coverage.