COMMISSION AGREEMENT
This COMMISSION AGREEMENT (the “Agreement”) is made this ____ day of
______________, 20____ by and among _____________________________ (“PRODUCER”)
and Delta Dental of Nebraska, a Nebraska nonprofit corporation (“DDNE”) or (“COMPANY.”)
WHEREAS, pursuant to the Independent Producer Agreement by and among
PRODUCER and DDNE, PRODUCER has agreed to solicit the sale of and sell a portion of
DDNE’s insurance programs and policies (the “IPA”); and
WHEREAS, pursuant to the IPA, compensation for the solicitation of and sale of such
insurance programs and policies shall be as set forth in this Agreement.
NOW THEREFORE, for good and valuable consideration, the receipt and adequacy of
which are hereby acknowledged, PRODUCER and COMPANY hereby agree as follows:
1.

COMPENSATION:
POOL Rated Group Programs

Pool rated groups include any DDNE dental program or vision program sold on a pool rated
basis. All pool rated groups covered by this Agreement are sold at rates pre-established by
DDNE.
Unless otherwise negotiated, COMPANY agrees to pay PRODUCER a commission as noted on
Exhibit A of this Agreement on behalf of any qualified group administrator designating
PRODUCER as “Agent of Record” per DDNE’s Master Dental Group Contract Application and
Master Vision Group Contract Application and signed by such qualified group administrator and
PRODUCER or signed by such qualified group administrator and PRODUCER.
INDIVIDUALLY Rated Group Programs
Unless otherwise negotiated, COMPANY agrees to establish commission rates based upon
projected annual revenue at the time of underwriting and pay PRODUCER at the established
rates on first year and subsequent years’ premium paid in cash to DDNE under any individually
rated group dental program or group vision program sold by DDNE, is advised in advance of
quoting rates that the PRODUCER is designated as Agent of Record for the specific group.
INDIVIDUAL AND FAMILY Insurance Programs
Unless otherwise negotiated, COMPANY agrees to pay PRODUCER a commission as noted on
Exhibit A of this Agreement for premium paid in cash to DDNE on all individual/family
insurance policies offered, including those consistent with the terms of the Patient Protection and
Affordable Care Act on which PRODUCER is designated as the Agent of Record for the specific
individual/family policy.

2.

TERMS:

(a)
This Agreement, including, but not limited to, the effective date, term, and
termination provisions, shall be governed by the terms set forth in the IPA. In the event of an
inconsistency between this Agreement and the IPA, the IPA shall govern.
(b)

PRODUCER’s territory for purposes of this Agreement and the IPA is Nebraska.

(c)
Commissions, subject to the terms and conditions of the IPA, shall be paid to the
PRODUCER as long as PRODUCER:
i. is continuously and actively engaged as a licensed insurance producer;
ii. continues to be designated by the group named in the Master Dental Group
Contract, the Master Vision Group Contract, the Individual/Family Dental
Contract, and the Individual/Family Vision Contract as the PRODUCER with
respect to such group/individual;
iii. services the group/individual in a manner satisfactory to COMPANY; and
iv. the original Master Dental Group Contract, Master Vision Group Contract,
Individual/Family Dental Contract, and the Individual/Family Vision Contract for
which this Agreement is executed have not been terminated.
(d)
Upon receipt of a completed and signed Taxpayer Identification Number Request
or W-9 Form, commissions shall be payable to the extent respective dues are paid to COMPANY
within thirty (30) days after the end of the calendar month. If a premium adjustment shall be
made for any period, then a corresponding adjustment shall be made in PRODUCER’s
commission for such period and adjustment made on next commission payment or refunded at
COMPANY’s option.
(e)
Any indebtedness of PRODUCER to COMPANY shall be first lien against any
commissions due PRODUCER or his, her, or its representative or assigns under this Agreement
and the IPA and such commissions shall be applied to liquidate such indebtedness.
(f)
No assignment, transfer or disposal of any interest that PRODUCER may have on
account of the Agreement shall be made at any time without written approval of COMPANY.
(g)
COMPANY may, at its option, be responsible for enrolling and servicing the
group or individual, and PRODUCER hereby agrees to abide by the elected option of
COMPANY, however, in either event, PRODUCER agrees to render satisfactory services as
directed by COMPANY.
(h)
By signing this Agreement, PRODUCER represents that PRODUCER is a duly
licensed insurance producer in the States in which PRODUCER is conducting sales and that no
disciplinary actions are pending against PRODUCER.
[Rest of page intentionally left blank. Signature page follows.]

2

IN WITNESS WHEREOF, PRODUCER and COMPANY, by authorized
representatives, as applicable, have executed this Agreement to be effective as of the effective
date of the IPA.
PRODUCER:

DELTA DENTAL OF NEBRASKA:

By:

By:

Print Name:

Print Name:

Title:

Title:

Date:

Date:

Resident State:
Resident Producer Lic. No.

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Exhibit A
POOL Rated Group Programs
Small Group - COMPANY agrees to pay PRODUCER 10% commission on first year and
subsequent years’ premium paid in cash to DDNE on small group dental plans offered on behalf
of any qualified group administrator designating PRODUCER as “Agent of Record” for the
specific group, unless otherwise negotiated.
Health Care Reform Certified Small Group - COMPANY agrees to pay PRODUCER
5% commission on first year and subsequent years’ premium paid in cash to DDNE on certified
small group standalone dental including those consistent with the terms of the Patient Protection
and Affordable Care Act on behalf of any qualified group administrator designating
PRODUCER as “Agent of Record” for the specific group, unless otherwise negotiated.
DeltaVision - Commission for DDNE’s Master Vision Group Contract(DeltaVision) will be
determined when the DeltaVision product is offered and an updated Exhibit A will be provided
at that time.

INDIVIDUAL AND FAMILY Insurance Programs
Unless otherwise negotiated, COMPANY agrees to pay PRODUCER 5% commission on first
year and subsequent years’ premium paid in cash to DDNE on all individual/family insurance
policies offered, including those consistent with the terms of the Patient Protection and
Affordable Care Act on which PRODUCER is designated as the Agent of Record for the specific
individual/family policy.

This Exhibit A is effective as of January 1, 2015, and may be modified by COMPANY pursuant
to Section 6(c) of the IPA.

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