Producer Contracting- 2023 UPDATE

If you are working with a GA/MGA, please enter the agency or principal's name below. If you are not working with a GA/MGA, type DIRECT.*

Name*

First NameLast Name

MaleFemale

Birth Date*

MonthDayYear

Social Security Number*

Email*

Resident Address*

Street Address

Street Address Line 2

CityState

Zip Code

Business Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Area CodePhone Number

Resident State Insurance License Number*

NPN*

Driver's License #*

Driver's License State*

Are you doing business as an agency or a corporation?*

NoYes

Name of Agency or Corporation (If you selected "No" above, type NA.)*

Agency Resident Insurance License Number (If you selected "No" above, type NA.)*

Agency NPN (If you selected "No" above, type "0".)*

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?*

YesNo

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

YesNo

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

YesNo

Have you ever been convicted of or plead guilty or no contest to a violation of federal or stat securities or investment related regulations?*

YesNo

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

YesNo

Have you ever been charged with a Felony?*

YesNo

Have you ever been charged with a Misdemeanor?*

YesNo

Have you ever been on probation?*

YesNo

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?*

YesNo

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

YesNo

Have you been under investigation by any insurance company?*

YesNo

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

YesNo

Have you ever been named as a defendant or codefendant in a lawsuit, or have you ever sue or been sued by an insurance company?*

YesNo

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

YesNo

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

YesNo

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?*

YesNo

Were you fired because you were accused of violating insurance or investment relate statures, regulations, rules or industry standards of conduct?*

YesNo

Were you fired because you were accused of fraud or the wrongful taking of property?*

YesNo

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

YesNo

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

YesNo

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?*

YesNo

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?*

YesNo

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

YesNo

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

YesNo

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

YesNo

Has any state or federal regulatory body found you to have been a cause of an investment – or insurance – related business ess having its authorization to do business denied, suspended, revoked, or restricted?*

YesNo

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

YesNo

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

YesNo

Have you had any interruptions in licensing?*

YesNo

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?*

YesNo

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

YesNo

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

YesNo

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

YesNo

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

YesNo

Have you personally filed a bankruptcy petition or declared bankrtuptcy?*

YesNo

Has any insurance or securities brokerage firm with whom you have been associated filed bankruptcy petition or been declared bankrupt either during your association or within five years after termination of such association?*

YesNo

Is the bankruptcy pending?*

YesNo

Are there any unsatisfied judgments, garnishments or liens against you?*

YesNo

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

YesNo

Have you ever used any other names or aliases?*

YesNo

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

YesNo

If you answered "yes" to any oof the above questions, please provide an explanation in the box below or upload any documentation.*

Background Question Documentation

Browse Files

Please upload a copy of your certificate of E&O*

Browse Files

New Producer Contracting

Demographics

Legal Questions for Contracting and Appointment Requests

Carrier Appointment Requests

Direct Deposit Authorization