Flash Packet Contracting Request

Producer Set-Up
Primary Insurance Market

AnnuitiesEmployee BenefitsHealthLifeSenior CareOther
Name*

First NameMiddle InitialLast Name
Maiden Name
SS#*
Date of Birth*

MonthDayYear
Date
Drivers License #*
Drivers License State*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Mobile

Area CodePhone Number
Gender*
Marital Status*
Mailing Street Address (No PO Boxes)*
Mailing Zipcode*
Start Date*

MonthDayYear
Date
Resident Street Address (No PO Boxes)*
Resident Zipcode*
Resident Start Date*

MonthDayYear
Date
Doing Business As

Individual AgentAgent of AgencySolicitor / LOA

E&O Coverage
Upload E&O Certificate*

Browse Files

Cancelof

Electronic Funds Transfers (EFT)
Account Owner Name*
Transit/ABA #*
Account #*
Financial Institution Name*
Branch Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Account Type*

CheckingSavings
Branch Phone Number*

Area CodePhone Number
By signing below I hereby authorize the Company to initiate credit entries and, if necessary, adjustments for credit entries in error to the checking and/or savings account indicated on this form. This authority is to remain in full effect until the Company has received written notification from me of its termination.
I understand that this authorization is subject to the terms of any agent or representative contract, commission agreement, or loan agreement that I may have now, or in the future, with the Company.
EFT Signature*

Clear
EFT Signature Date*

MonthDayYear
Date
Attach a copy of a check here for checking account or deposit slip for savings account*

Browse Files

Cancelof

Employment History

Please provide past 10 years of employment history.
Employment History*

Address History

Please provide past 5 years of address history.
Address History*

Signature Authorization
I, Full Name*, hereby authorize
SuranceBay, LLC and its general agency customers (the “Authorized
Parties”) to affix or append a copy of my signature, as set forth below,
to any and all required signature fields on forms and agreements of
any insurance carrier (a “Carrier”) designated by me through the
SureLC software or through any other means, including without
limitation, by e-mail or orally. The Authorized Parties shall be
permitted to complete and submit all such forms and agreements on
my behalf for the purpose of becoming authorized to sell Carrier
insurance products. I hereby release, indemnify and hold harmless the
Authorized Parties against any and all claims, demands, losses,
damages, and causes of action, including expenses, costs and
reasonable attorneys' fees which they may sustain or incur as a result
of carrying out the authority granted hereunder.
By my signature below, I certify that the information I have submitted
to the Authorized Parties is correct to the best of my knowledge and
acknowledge that I have read and reviewed the forms and agreements
which the Authorized Parties have been authorized to affix my
signature. I agree to indemnify and hold any third party harmless from
and against any and all claims, demands, losses, damages, and causes
of action, including expenses, costs and reasonable attorneys' fees
which such third party may incur as a result of its reliance on any form
or agreement bearing my signature pursuant to this authorization.
Signature*

Clear
From Name
From Email
example@example.com
Upline
Level
Should be Empty:

	Yes	No
1 Have you ever been charged or convicted of or plead guilty or no contest to any Felony, Misdemeanor, federal/state insurance and/or securities or investments regulations or statutes? Have you ever been on probation?
1A Have you ever been convicted of or plead guilty or no contest to any Felony?
1B Have you ever been convicted of or plead guilty or no contest to any Misdemeanor?
1C Have you ever been convicted of or plead guilty or no contest to a violation of federal or state securities or investment related regulations?
1D Have you ever been convicted of or plead guilty or no contest to a violation of state insurance department regulations or statutes?
1E Has any foreign government, court, regulatory agency, or exchange ever entered an order against you related to investments or fraud?
1F Have you ever been charged with a Felony?
1G Have you ever been charged with a Misdemeanor?
1H Have you ever been on probation?
2 Have you ever been or are you currently being investigated, have any pending indictment, lawsuits, or have you ever been in a lawsuit with an insurance company?
2A Are you currently under investigation by any legal or regulatory authority?
2B Have you been under investigation by any insurance company?
2C Have you ever been or are you currently involved in any pending indictments, lawsuits, civil judgments or other legal proceedings (civil or criminal)(you may omit family court).
2D Have you ever been named as a defendant or codefendant in a lawsuit, or have you ever sued or been sued by an insurance company?
3 Have you ever been alleged to have engaged in any fraud?
4 Have you ever been found to have engaged in any fraud?
5 Has any insurance or financial services company or broker-dealer terminated your contract or appointment or permitted you to resign for reason other than lack of sales?
5A Were you fired because you were accused of violating insurance or investment related statures, regulations, rules or industry standards of conduct?
5B Were you fired because you were accused of fraud or the wrongful taking of property?
5C Failure to supervise in connection with insurance or investment related statues, regulations, rules or industry standards of conduct?
6 Have you ever had an appointment with any insurance company denied or terminated for cause?
7 Does any insurer, insured, or other person claim any commission chargeback or other indebtedness from you as a result of any insurance transactions or business?
8 Has any lawsuit or claim ever been made against you, your surety company, or errors and omissions insurer arising out of your sales or practices, or, have you been refused surety bonding or E&O coverage?
8A Has a bonding or surety company ever denied, paid on or revoked a bond for you?
8B Has any Errors & Omissions (E&O) carrier ever denied, paid claims on or cancelled your coverage?
9 Have you ever had an insurance or securities license denied, suspended, cancelled or revoked?
10 Has any state or federal regulatory body found you to have been a cause of an investment – or insurance – related business having its authorization to do business denied, suspended, revoked, or restricted?
11 Has any state or federal regulatory agency revoked or suspended your license as an attorney, accountant, or federal contractor?
12 Has any state or federal regulatory agency found you to have made a false statement or omission or been dishonest, unfair, or unethical?
13 Have you had any interruptions in licensing?
14 Has any state, federal or self-regulatory agency filed a complaint against you, fined, sanctioned, censured, penalized or otherwise disciplined you for a violation of their regulations or state or federal statutes? Have you ever been the subject of a consumer initiated complaint?
14A Has any regulatory body ever sanctioned, censured, penalized or otherwise disciplined you?
14B Has any state, federal, or self-regulatory agency filed a complaint against you, fined or sanctioned you?
14C Have you ever been the subject of a consumer initiated complaint?
15 Have you personally or any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or declared bankruptcy?
15A Have you personally filed a bankruptcy petition or declared bankrtuptcy?
15B Has any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or been declared bankrupt either during your association or within five years after termination of such association?
15C Is the bankruptcy pending?
16 Are there any unsatisfied judgments, garnishments or liens against you?
17 Are you connected in any way with a bank, savings & loan association, or other lending or financial institution?
18 Have you ever used any other names or aliases?
19 Do you have any unresolved matters pending with the Internal Revenue Service or other taxing authority?

Information

Carrier Contracting Requirements & Guidelines

Producer Set-Up

Legal Questions for Contracting and Appointment Requests

E&O Coverage

Electronic Funds Transfers (EFT)

Employment History

Address History

Signature Authorization