AGENCY INFORMATION
Legal Name of Agency
DBA (if applicable)
Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different from Physical)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone
-
Area Code
Phone Number
Website
If none, please indicate N/A
Entity NPN #
Entity FEIN #
Ownership Type
Corporation
LLC
Partnership
Proprietorship
Individual
E&O Carrier
E&O Policy Number
E&O Limits
Minimum $1,000,000 limit required
Year Agency Founded
Office Size
Number of Team Members including Support Staff
AGENCY PRINCIPAL INFORMATION
Full Legal Name of Agency Principal
*
First Name
Middle Name
Last Name
Suffix
Title
Email Address
example@example.com
NPN #
Number of Years Licensed
AGENCY PREMIUM & PRODUCTION
Please include all your Agency's combined locations
Total Agency Premium $
Total Homeowner Premium $
Total Condominium Premium $
Total Dwelling Premium $
Total Manufactured Homes Premium $
Total Commercial Premium $
CURRENT MONTHLY NEW BUSINESS PRODUCTION
Please include all Carriers
Personal Lines Quotes Submitted to Market
Personal Lines Quotes Bound
Commercial Lines Quotes Submitted to Market
Commercial Lines Quotes Bound
Top 4 Counties Where Your Agency Writes Business
Top 5 Insurance Companies Currently Appointed With
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INDIVIDUAL BACKGROUND QUESTIONS
* “Convicted” includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea of guilty or nolo contendere or no contest, or having been given probation, a suspended sentence, or a fine. ** “Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, a cease and desist order, a prohibition order, a compliance order, placed on probation, sanctioned or surrendering a license to resolve an administrative action. “Involved” also means being named as a party to an administrative or arbitration proceeding, which is related to a professional or occupational license, or registration. “Involved” also means having a license, or registration application denied or the act of withdrawing an application to avoid a denial. INCLUDE any business so named because of your actions in your capacity as an owner, partner, officer or director, or member or manager of a Limited Liability Company. You may EXCLUDE terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee.
Have you ever been convicted* of a misdemeanor, had a judgment withheld or deferred, or are you currently charged with committing a misdemeanor? You may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, driving under the influence (DUI), driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license. You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court).
Yes
No
Have you ever been convicted* of a felony, had a judgment withheld or deferred, or are you currently charged with committing a felony? You may exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court).
Yes
No
If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of insurance in your home state as required by 18 USC 1033? If this question is not applicable, select N/A.
Yes, and consent was granted.
Yes, but consent was not granted.
No
N/A
Have you ever been convicted* of a military offense, had a judgment withheld or deferred, or are you currently charged with committing a military offense? If you answer "YES" to any of these questions, you must attach to this application: a) a written statement explaining the circumstances of each incident, b) a copy of the charging document, a copy of the official document, which demonstrates the resolution of the charges or any final judgment.
Yes
No
Have you ever been named or involved** as a party in an administrative proceeding, including FINRA sanction or arbitration proceeding regarding any professional or occupational license or registration? If you answer "YES", you must attach to this application: a) a written statement identifying the type of license and explaining the circumstances of each incident, b) a copy of the Notice of Hearing or other document that states the charges and allegations, and a copy of the official document which demonstrates the resolution of the charges or any final judgment.
Yes
No
Has any demand been made or judgment rendered against you or any business in which you are or were an owner, partner, officer or director, or member or manager of a limited liability company, for overdue monies by an insurer, insured or producer, or have you ever been subject to a bankruptcy proceeding? Do not include personal bankruptcies, unless they involve funds held on behalf of others. If you answer "YES", submit a statement summarizing the details of the indebtedness and arrangements for repayment, and/or type and location of bankruptcy.
Yes
No
Have you been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is not the subject of repayment agreement? If you answer “YES”, identify the jurisdiction(s).
Yes
No
Are you currently a party to, or have you ever been found liable in, any lawsuit, arbitration or mediation proceeding involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty? If you answer "YES", you must attach to this application: a) a written statement summarizing the details of each incident, b) a copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, or mediation proceedings, and a copy of the official documents, which demonstrates the resolution of the charges or any final judgment.
Yes
No
Have you or any business in which you are or were an owner, partner, officer or director, or member or manager of a limited liability company, ever had an insurance agency contract or any other business relationship with an insurance company terminated for any alleged misconduct? If you answer "YES", you must attach to this application a written statement summarizing the details of each incident and explaining why you feel this incident should not prevent you from receiving an insurance license, and copies of all relevant documents.
Yes
No
Do you have a child support obligation in arrearage? If you answer “YES”, provide documentation showing proof of current payments or an approved repayment plan from the appropriate state child support agency?
Yes
No
If yes, how many months are you in arrearage?
If yes, are you currently subject to and in compliance with the repayment agreement?
Yes
No
N/A
If yes, are you the subject of a child support related subpoena / warrant?
Yes
No
N/A
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BUSINESS ENTITY BACKGROUND QUESTIONS
* “Convicted” includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea of guilty or nolo contendere or no contest, or having been given probation, a suspended sentence, or a fine. ** “Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, a cease and desist order, a prohibition order, a compliance order, placed on probation, sanctioned or surrendering a license to resolve an administrative action. “Involved” also means being named as a party to an administrative or arbitration proceeding, which is related to a professional or occupational license, or registration. “Involved” also means having a license, or registration application denied or the act of withdrawing an application to avoid a denial. INCLUDE any business so named because of your actions in your capacity as an owner, partner, officer or director, or member or manager of a Limited Liability Company. You may EXCLUDE terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee.
Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company, ever been convicted* of a misdemeanor,had a judgment withheld or deferred or is the business entity or any owner, partner, officer or director of the business entity, or member or manager currently charged with, committing a misdemeanor? You may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, driving under the influence (DUI),driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license.
Yes
No
Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company, ever been convicted* of a felony, had a judgment withheld or deferred or is the business entity or any owner, partner,officer or director of the business entity or member or manager of a limited liability company currently charged with, committing a felony? You may exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court).
Yes
No
If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of insurance in your home state as required by 18 USC 1033? If this question is not applicable, enter N/A.
Yes
No
N/A
If so, was consent granted? (Attach copy of 1033 consent approved by home state.) If this question is not applicable, enter N/A.
Yes
No
N/A
Has the business entity or any owner, partner, officer or director of the business entity or member or manager of a limited liability company, ever been convicted* of a military offense, had a judgment withheld or deferred, or is the business entity or any owner, partner, officer or director of the business entity or member or manager of a limited liability company, currently charged with committing a military offense? If you answer "YES" to any of these questions, you must attach to this application: a) a written statement identifying all parties involved (including their percentage of ownership, if any) and explaining the circumstances of each incident; b) a copy of the charging document, a copy of the official document, which demonstrates the resolution of the charges or any final judgment.
Yes
No
Has the business entity or any owner, partner, officer or director of the business entity, or manager or member of a limited liability company, ever been named or involved** as a party in an administrative proceeding, including a FINRA sanction or arbitration proceeding regarding any professional or occupational license, or registration? If you answer "YES", you must attach to this application: a) a written statement identifying the type of license, all parties involved (including their percentage of ownership, if any) and explaining the circumstances of each incident; b) a copy of the Notice of Hearing or other document that states the charges and allegations, and a copy of the official document which demonstrates the resolution of the charges or any final judgment.
Yes
No
Has any demand been made or judgment rendered against the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company, for overdue monies by an insurer, insured or producer, or have you ever been subject to a bankruptcy proceeding? Do not include personal bankruptcies, unless they involve funds held on behalf of others. If you answer "YES", submit a statement summarizing the details of the indebtedness and arrangements for repayment.
Yes
No
Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company, ever been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is not the subject of a repayment agreement? If you answer "YES", identify the jurisdiction(s).
Yes
No
Is the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company, a party to, or ever been found liable in any lawsuit or arbitration proceeding involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty? If you answer "YES", you must attach to this application: a) a written statement summarizing the details of each incident, b) a copy of the Petition, Complaint or other document that commenced the lawsuit arbitrations, or mediation proceedings and a copy of the official documents which demonstrates the resolution of the charges or any final judgment.
Yes
No
Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company ever had an insurance agency contract or any other business relationship with an insurance company terminated for any alleged misconduct? If you answer "YES", you must attach to this application a written statement summarizing the details of each incident and explaining why you feel this incident should not prevent you from receiving an insurance license, and copies of all relevant documents.
Yes
No
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Agreement and Submission
As the Agency Principal, I hereby declare the information provided in this questionnaire to be true and correct. When completed, click Submit. If you have any questions about this application or our agency on-boarding process, please contact info@ssiuw.com or Mindy Dees, Operations Director, at 251.923.4472.
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