CIA Inquiry

CIA Agent Inquiry
Name*

First NameLast Name
Email*
example@example.com
Mobile Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Current situation:*
What is your current role?*

Agency OwnerTeam member
What insurance licenses do you currently hold? (e.g., Life, Health, P&C)*

P&CLifeHealthOther
Years of Insurance Industry Experience?*
Planned Business Location*
Do you have a dedicated home office?*

Describe Your Present Situation and what has you exploring new opportunity?*
What is your primary focus?*
Are you looking to add P&C to be:*

Additional product offeringPrimary focus
What are your most important needs?*
What is your timeline for making a decision?*

What is your current total premium amount? Numerical format only*** *
Ex: $#,###,###
What % is personal lines vs commercial lines?*
Which carriers do you currently have access to*
Which carriers are you most interested in gaining access to?*
What are your production goals during your first 12 months? Numerical format only****
Ex: $#,###,###

What specific types of support are you looking for from CIA? (e.g., marketing, training, administrative)*
Do you currently have a team or plan to build one? If so, please describe.*
Are there specific geographic areas you focus on or plan to focus on?*
Additional Information/Concerns: non-competes, previous criminal convictions, carrier terminations, bankruptcy, etc… *

This non-disclosure agreement is between Career Insurance Agents (CIA) and Prospective Agent of this agreement. Whereas CIA and Prospective Agent wish to exchange certain information pertaining to the operations and contractual obligations of CIA and its independent contractors, these two parties hereby agree to the following conditions:
1. CIA will provide Prospective Agent with an original copy “Draft” of its standard Agency/Agent contract. In addition, CIA will provide Prospective Agent with additional information, both orally and in writing, as to the operations and benefits of becoming an Independent Contractor with CIA.
2. Prospective Agent agrees not to share this information with any third parties not explicitly approved by CIA and to use reasonable and practical care to protect and maintain possession of the contract and any other materials provided to Prospect by CIA. This applies not only to all original documents, but to all copies that may have been made by or supplied to Prospect.
3. Upon request of CIA, Prospective Agent will return all documents, materials, and notes both originals and copies to CIA within 15 days of the request.
4. In the event of a breach or threatened breach of this Agreement, CIA shall be entitled to preliminary and final injunctions, in addition to any other rights and remedies available to it at law or in equity.
5. The validity and performance of this contract are governed by the laws of the State of Colorado.
6. This Agreement is binding upon the directors, officers, employees and agents of each party and will continue indefinitely, with the obligations of confidentiality surviving the termination of this Agreement.
I agree
How did you hear about CIA?*
Name of CIA agent that referred you?*
Which podcast?*
Date Signed:

MonthDayYear
Date
Hour MinutesAM/PM Option
Signature*

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CIA Agent Inquiry