AGENT / AGENCY DISCOVERY QUESTIONNAIRE
WELCOME! Please answer the following questions to assist us in welcoming you and your business.
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Part I: General Information
Are you working with a Sales Director? If no one, please choose N /A.
*
Please Select
Andrea Ames
Brandon Herndon
Charlie Archer
Clayton Lund
Deven Hennessey
Donnie Clossman
Durr Sexton
Dustin Weaver
Mark Fayak
Michelle Gotham
Pablo Martinez
Paul Davis
Ricci Nelson
Roger Stacy
Shara Sutton
Tom Archer
N / A
Are you applying as an Agent or an Agency?
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Agent
Agency
Agency / Business Name:
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Agency Website URL:
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Are you a Brokerage?
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Yes
No
How many agents in your downline? If none, enter 0
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Agent Name:
*
First Name
Last Name
Title:
Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Format: (000) 000-0000.
E-mail:
*
example@example.com
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Part II: Licensing Information
In this section we are collecting data about your existing license(s).
N P N?
*
In which state is your resident license issued?
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Resident license number:
Is your resident license active?
*
Please Select
Yes
No
Is this a corporate license?
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Yes
No
In what other states are you licensed?
AL
IL
MT
RI
AK
IN
NE
SC
AZ
IA
NV
SD
AR
KS
NH
TN
CA
KY
NJ
TX
CO
LA
NM
UT
CT
ME
NY
VT
DC
MD
NC
VA
DE
MA
ND
WA
FL
MI
OH
WV
GA
MN
OK
WI
HI
MS
OR
WY
ID
MO
PA
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Part III: Existing Appointments Information
In this section we are collecting data about your existing carrier appointments
How many carriers are you appointed with?
Which of these Life carriers are you appointed with?
Cincinnati Life
National Life
Columbus
Nationwide
Corebridge (American General)
North American
John Hancock
Pacific Life
Legal and General (Banner)
Principal
Lincoln
Protective
Mass Mutual
Securian
Mutual of Omaha
Other
Which of these Annuity carriers are you appointed with?
American National
Lincoln
Athene
North American
Corebridge
Other
Which of these Disability insurance carriers are you appointed with?
Ameritas
Petersen International
Assurity
Principal
Other
Which of these Health insurance carriers are you appointed with?
Aetna
Humana
BlueCross BlueShield
Mutual of Omaha
Other
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Part III-B: Group Information
In this section we are collecting data about Group Insurance
Do you currently sell Group insurance products?
Yes
No
Approximately how many Group clients do you currently have?
What size groups do you typically work with?
Small Group : Less than 50
Mid Size Group : 50 - 250
Large Group : More than 250
Which lines of group coverage are you most interested in offering?
Medical
Dental
Vision
Life
Disability
Voluntary Benefits
Other
Other
In which states do you hold an active Health license?
AL
IL
MT
RI
AK
IN
NE
SC
AZ
IA
NV
SD
AR
KS
NH
TN
CA
KY
NJ
TX
CO
LA
NM
UT
CT
ME
NY
VT
DC
MD
NC
VA
DE
MA
ND
WA
FL
MI
OH
WV
GA
MN
OK
WI
HI
MS
OR
WY
ID
MO
PA
In which states do you hold an active Life license?
AL
IL
MT
RI
AK
IN
NE
SC
AZ
IA
NV
SD
AR
KS
NH
TN
CA
KY
NJ
TX
CO
LA
NM
UT
CT
ME
NY
VT
DC
MD
NC
VA
DE
MA
ND
WA
FL
MI
OH
WV
GA
MN
OK
WI
HI
MS
OR
WY
ID
MO
PA
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Part IV: Technical Information
In this section we are collecting data about your technology infrastructure
Do you have access to the following platforms (check all that apply)
*
Agency Bloc
FireLight
Agency Integrator
SmartOffice
Ensight
SureLC
Express Complete
Winflex
Other
Which CRM or AMS do use?
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Salesforce
HQ One
HubSpot
Zoho CRM
Other
Which Social Media tools do you use? Check all that apply.
*
Facebook
Twitter
Youtube
LinkedIn
Yelp
Foursquare
TripAdvisor
Instagram
Tumblr
Google+
Pinterest
Flickr
Vine
Urbanspoon
About.me
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Part V: Agency Information & Structure
In this section we are collecting data about your Agency Structure
Officer Names: Please list the names and titles of your agency's officers.
Rows
Name
Telephone
Email
Principal
Officer 1
Officer 2
Number of office locations: How many physical office locations does your agency operate?
Primary Headquarters location:
Company Structure:
Single Proprietorship
Partnership
LLC
C Corporation
S Corporation
Other
Principal Signer: Who is the principal signer for your agency, as listed with the State Department of Insurance?
Employee Count: How many employees does your agency currently have?
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Part V: Business Model & Client Base
In this section we are collecting data about your business model.
Go-to-Market Strategy: How does your entity go to market?
BGA
IMO
IRA
Bank
Investment Firm
Other
Total Client Count: Approximately how many clients does your agency serve?
Assets Under Management: Approximately how many assets does your agency manage?
Affluent Client Count: Of your total client base, how many would you classify as affluent?
Net Worth $100,000.00 to $1,000,000.00
High Net Worth Clients: how many of your clients are considered high net worth individuals?
Net Worth $1 Million and up.
Anything else we need to understand about you or your business? If nothing, type N/A.
*
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