Contracting/ Onboarding Form

Initial Onboarding Form
This form will provide Agent Equity Group with all the information we need to set you up in our system and start the contracting process.

Upon completion, we will email you detailed instructions for each carrier you wish to be contracted with.

If you're an agency, please fill this form out in the name of the main agency principal.

You will need to attach a copy of your resident state insurance license, current E&O, and a voided check.

The form should take you 10-20 minutes to complete.

Don't hesitate to contact us with any questions.

contracting@agentequitygroup.com

616-226-4111

Contracting Type
Contracting Type?*
Agency you are your assigning commissions to
The name of the agency you are affiliated with.

Personal Information
Name*

First NameMiddle NameLast NameSuffix
Gender*

MaleFemaleOther
Date of Birth*

MonthDayYear
Date
SSN*
NPN*
Marital Status

MarriedSingleDivorced
Maiden Name
Driver's License Number*
Driver's License State*

Street Address

Street Address Line 2

CityState

Zip Code

Contact Information
Email
example@example.com
Business Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Personal Address History (Past 5 Years)*
Employment History (Past 5 Years)*

Agency Information

Only complete if you own an agency.
Agency Name*
Company Type

CorpLLCPartnershipLLP
Agency Tax ID*
Agency NPN*
Agency Business Address

Street Address

Street Address Line 2

CityState

Zip Code

Licenses
States Licensed
AML Provider (for Life and Annuity contracts)

LIMRANoneOther
Last AML Completion Date

MonthDayYear
Date
Are you an Investment Advisor registered with the SEC?*

YesNo
Are you a Registered Rep with FINRA?*

YesNo
Broker Dealer Name
CRD Number (if SEC or Finra)
List any designations or honors you hold:
Please attach your agent/ agency state licenses.*

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Electronic Funds Transfer (EFT) Info

If you are an agency, please enter your business checking only. Skip if LOA.
Bank Account Owner Name:*

First NameLast Name
Bank Routing Number:*
Bank Account Number:*
Bank Account Type:*

CheckingSavings
Bank Name:*
Bank Address:*
Bank Phone:*
Please enter a valid phone number.
By signing below I hereby authorize the Company to initiate credit entries and, if
necessary, adjustments for credit entries in error 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 on the future, with the Company.
Signature*

Powered by Jotform SignClear
Signature Date*

MonthDayYear
Date
Please attach a voided check for checking account or deposit slip for saving account:*

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Errors & Omissions
Carrier*
Certificate Number*
Effective Date*

MonthDayYear
Date
Termination Date*

MonthDayYear
Date
Please attach a copy of your Errors and Omissions Certificate.*

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Commission Advancing/ Beneficiary

Skip if LOA.
Medicare Supplement Commission Advancing:

None6 Months9 Months12 Months
Life Insurance Commission Advancing:

None6 Months9 Months
Some carriers allow you to provide a commission beneficiary. Please complete the following if you would like to list a beneficiary.
Beneficiary Name
Beneficiary Relationship

Signature Authorization
The SuranceBay contracting platform requires a wet signature authorization. This form provides us with a limited power of attorney to complete carrier contracting on your behalf.
Print this form. Complete and attach below.
Please upload your signature authorization form.*

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Agent Comments
Should be Empty:

	Yes	No
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 investment regulations or statutes? Have you ever been on probation?
Have you ever been convicted of or plead guilty or no contest to any Felony?
Have you ever been convicted of or plead guilty or no contest to any Misdemeanor?
Have you ever been convicted of or plead guilty or no contest to a violation of federal or state securities or investment related regulations?
Have you ever been convicted of or plead guilty or no contest to a violation of state insurance department regulations or statutes?
Has any foreign government, court, regulatory agency, or exchange ever entered an order against you related to investments or fraud?
Have you ever been charged with a Felony?
Have you ever been charged with a Misdemeanor?
Have you ever been on probation?
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?
Are you currently under investigation by any legal or regulatory authority?
Have you been under investigation by any insurance company?
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).
Have you ever been named as a defendant or co-defendant in a lawsuit, or have you ever sued or been sued by an insurance company?
Have you ever been alleged to have engaged in any fraud?
Have you ever been found to have engaged in any fraud?
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?
Were you fired because you were accused of violating insurance or investment related statures, regulations, rules or industry standards of conduct?
Were you fired because you were accused of fraud or the wrongful taking of property?
Failure to supervise in connection with insurance or investment related statues, regulations, rules or industry standards of conduct?
Have you ever had an appointment with any insurance company denied or terminated for cause?
Does any insurer, insured, or other person claim any commission charge-back or other indebtedness from you as a result of any insurance transactions or business?
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 beenrefused surety bonding or E&O coverage?
Has a bonding or surety company ever denied, paid on or revoked a bond for you?
Has any Errors & Omissions (E&O) carrier ever denied, paid claims on or canceled your coverage?
Have you ever had an insurance or securities license denied, suspended, canceled or revoked?
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?
Has any state or federal regulatory agency revoked or suspended your license as an attorney, accountant, or federal contractor?
Has any state or federal regulatory agency found you to have made a false statement or omission or been dishonest, unfair, or unethical?
Have you had any interruptions in licensing?

Initial Onboarding Form

Contracting Type

Personal Information

Contact Information

Agency Information

Licenses

Electronic Funds Transfer (EFT) Info

Errors & Omissions

Legal Questions

Commission Advancing/ Beneficiary

Signature Authorization