SIG Paperwork - Brian Askins FINAL

Social Security *

Email *

example@example.com

Last Name *

First Name *

MI *

Resident Insurance License # *

State *

Phone Number *

Fax *

Cell Phone *

Gender *

Driver’s License # / State: *

Title *

Marital Status *

Date of Birth *

Date

Maiden Name *

Move-in Date: *

Residential Address *

Address

Street Address Line 2

State / Province

ZIP Code

Mailing Address *

Address

Street Address Line 2

City/State

ZIP Code

AML Provider: *

LIMRA NONE OTHER

If other, provide certificate of completion.

AML Completion Date *

Date

Are you a registered rep with FINRA? *

Yes No

CRD# *

Please list any Honors you currently hold *

Doing Business As: *

Individual Business Entity Solicitor/LOA

If DBA Solicitor/LOA, list who you are assigning commissions to: *

EIN *

Business Name *

Website *

Your Title *

Phone *

Fax *

Principal Name *

Principal Title *

Email *

example@example.com

Corporate Address (No PO Boxes) Start Date *

Date

Line 1 *

Line 2 *

Zip Code *

SureLC Licensing Questionnaire

Please answer the following questions. If you answer YES to any question, be sure to provide an attached letter that is signed with a full, detailed explanation including specific dates.

1. Have you ever been charged or convicted of or plead guilty or no contest to any Felony, Misdemeanor? *

Yes No

1A. Have you ever been convicted of or plead guilty or no contest to any Felony? *

Yes No

1B. Have you ever been convicted of or plead guilty or no contest to any Misdemeanor? *

Yes No

1C. Have you ever been convicted of or plead guilty or no contest to a violation of federal or state? *

Yes No

1D. Have you ever been convicted of or plead guilty or no contest to a violation of state insurance department regulations or statutes? *

Yes No

1E. Has any foreign government, court, regulatory agency, or exchange ever entered an order against you related to investments or fraud? *

Yes No

1F. Have you ever been charge with a Felony? *

Yes No

1G. Have you ever been charged with a Misdemeanor? *

Yes No

1H. Have you ever been on probation? *

Yes No

2. Have you ever been or are you currently being investigated, have any pending indictments, lawsuits, or have you ever been in lawsuit with insurance company? *

Yes No

2A. Are you currently under investigation by any legal or regulatory authority? *

Yes No

2B. Have you been under investigation by any insurance company? *

Yes No

2C. Have you ever been or are you currently involved in any pending indictments, lawsuits, civil judgements or other legal proceedings (civil or criminal) (you may omit family court)? *

Yes No

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? *

Yes No

3. Have you ever been alleged to have engaged in any fraud? *

Yes No

4. Have you ever been found to have engaged in any fraud? *

Yes No

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? *

Yes No

5A. Were you terminated/resigned because you were accused of violating insurance or investment related statutes, regulations, rules or industry standards of conduct? *

Yes No

5B. Were you terminated/resigned because you were accused of fraud or the wrongful taking of property? *

Yes No

5C. Failure to supervise in connection with insurance or investment related statues, regulations, rules or industry standards of conduct? *

Yes No

6. Have you ever had an appointment with any insurance company terminated for cause or been denied an appointment? *

Yes No

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? *

Yes No

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? *

Yes No

8A. Has a bonding or surety company ever denied, paid on or revoked a bond for you? *

Yes No

8B. Has any Errors & Omissions (E&O) carrier ever denied, paid claims on or cancelled your coverage? *

Yes No

9. Have you ever had an insurance or securities license denied, suspended, cancelled or revoked? *

Yes No

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? *

Yes No

11. Has any state or federal regulatory agency revoked or suspended your license as an attorney, accountant, or federal contractor? *

Yes No

12. Has any state or federal regulatory agency found you to have made a false statement or omission or been dishonest, unfair, or unethical? *

Yes No

13. Have you ever had any interruptions in licensing? *

Yes No

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? *

Yes No

14A. Has any regulatory body ever sanctioned, censured, penalized or otherwise disciplined you? *

Yes No

14B. Has any state, federal, or self-regulatory agency filed a complaint against you, fined or sanctioned you? *

Yes No

14C. Have you ever been the subject of a consumer initiated complaint? *

Yes No

15. Have you personally or any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or declared bankruptcy? *

Yes No

15A. Have you personally filed a bankruptcy petition or declared bankruptcy? *

Yes No

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? *

Yes No

15C. Is the bankruptcy pending? *

Yes No

16. Have you ever had any unsatisfied judgments, garnishments, or liens against you? *

Yes No

17. Are you connected in any way with a bank, savings & loan association, or other lending or financial institution? *

Yes No

18. Have you ever used any other names or aliases? *

Yes No

19. Do you have any unresolved matters pending with the Internal Revenue Service or other taxing authority? *

Yes No

If you answered any questions "yes," provide an explanation that includes dates, actions and descriptions. *

I attest that the information I have provided is true to the best of my knowledge. I acknowledge that if any information changes, I will notify my agency office within 5 days of such change. Further, I understand that my agency may contact me when I need to answer specific questions. I further understand and agree that this form and the information contained herein will be shared with First Heartland Corporation, its affiliated companies, and any other organization, entity, or person with whom I am seeking licensure, registration, or appointment.

Signature Required *

Clear

Date *

Date

Account Owner Name (Required) *

Transit/ABA Number *

Account Number *

Financial Institution Name *

Branch Address *

City *

State *

Zip *

Phone 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.

Signature Required *

Clear

Date *

Date

Attach copy of the check here for checking account or deposit slip for savings account *

I, hereby authorize SuranceBay, LLC, its general agency customers,

and First Heartland® (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 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 attorney’s 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 to 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 attorney’s 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.

Please sign in the box below.

Signature Required *

Clear

1.Do you want your commissions to be advanced with your appointments? *

Yes No

*Commission Advancing: Most carriers allow your first year commission to be paid in advance. Most carriers pay up to a 9 month advance.

2 What city were you born in *

3. What is your NPN *

4 Would you like to order SIG business cards? If yes, we will get in touch with you on the process *

Yes No

Please attach the following items below:

Any resident and nonresident Licenses
AML – If completed on LIMRA, provide login credentials
E&O

Attach Files Here *

SECURE INSURANCE GROUP

SECURE INSURANCE GROUP