Insurance Agent Information Request Form
Please complete this form and we will send you the contracting link to see if you will be approved. Allow 24-48 business hours for a response.
Personal Information
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the best time to contact you?
*
Please Select
Morning
Lunch Time
Evening
Afternoon
Doesn't Matter
How did you hear about this opportunity? (Please name person who referred you or where you saw the position posted)
Do you have a valid Florida Life & Health insurance license?
*
Yes
No
Position Information
What position are you applying for?
*
Please Select
Opener (Account Executive)
Enroller (Benefit Counselor)
ASR (opens groups and enrolls)
What is your available start date?
*
-
Month
-
Day
Year
Date
Are you bi-lingual?
No
Yes
If bi-lingual, please let us know what languages.
Have you ever been contracted with Colonial Life & Accident Insurance company before?
*
Yes
No
Please provide date you left Colonial and any information we need to consider
*
Please upload your Resume here
*
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Please upload your Cover Letter here
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Please acknowledge that you understand this is a 1099/commissioned compensation opportunity (which may include bonuses and renewal/residual compensation), and not a W-2 employment position.
*
Yes
No
Date
*
-
Month
-
Day
Year
Date
Signature
*
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