I agree to avoid disclosing or using any non-public personal information concerning the Company's
customers (including but not limited to the Company's policyholders, insureds, annuitants, claimants,
beneficiaries, and applicants). Information may include names, addresses, telephone numbers, birth
dates, Social Security numbers, insurance policy or annuity information, financial information or any
other personally identifiable information (such information to be referred to herein as "Company Customer
Information") for any purpose other than to carry out duties and functions as set forth in my Producer
Contract, or as otherwise permitted under federal or state law.
I agree to pay special attention to the use and disclosure of Protected Health Information (PHI) as is
defined in the Health Insurance Portability Act (HIPAA) of 1996. Specifically, I agree to establish and
implement appropriate safeguards for PHI that is created, received, used or disclosed in the performance
of the obligations under my contract.
Additionally, upon receiving a written request from the Company, I will make available in a timely manner
the information required by the Company to provide an accounting of the uses and disclosures of PHI in
accordance with the HIPAA privacy rule.
With respect to paper and electronic life insurance applications, I agree to establish appropriate safeguards
to protect against the inadvertent disclosure of the Company Customer Information to any other person or entity.
In the event of any improper or unauthorized disclosure of Company Customer Information while in my custody or
control, I will immediately notify the Company so that the Company and I may take appropriate remedial action. I
acknowledge that should I not establish appropriate safeguards to protect Company Customer Information and the
Company Customer Information is subject to any improper or unauthorized disclosure, I agree to indemnify and hold
the Company harmless for any and all costs incurred in relation to said disclosure, and acknowledge that I may be
subject to immediate termination by the Company.
COLUMBIAN MUTUAL LIFE INSURANCE COMPANY Home Office: Binghamton, NY 13902-1381
COLUMBIAN LIFE INSURANCE COMPANY Home Office: Chicago, IL
ADMINISTRATIVE SERVICE OFFICES: Binghamton, NY • Syracuse, NY