Velomon Advisor Signup

Name*

First NameLast Name
Email*
This should be the professional email address you want to use daily
Phone Number*
Please enter a valid phone number.
Gmail Address (if you don' have one, please set on up)*
This is needed to provide access to the Velomon back office - even if you don't use it professionally

If you are contracted with carriers whose products fit the objectives of your clients and you access those contracts through an IMO/FMO/BGA you are comfortable with or have a relationship with, it is not Velomon's intention to in any way interfere with those relationships. The following two questions are completely optional but do offer an introduction to one IMO and one Carrier who support what we do and provide products and services that are consistent with our goals and those of our clients.
Check here if you would like to be introduced to the Impact Partnership - our preferred IMO - to begin carrier contracting/gain access to insurance products that support our strategies

Yes, please make the introduction
Check here if you would like to become contracted with Midland National whose products fit our strategic objections. The Midland commission structure is 6% on a case that would normally pay 7%, but ELIMINATES any case splits (more retained commission for you). Midland also offers production bonuses that can increase the commission rate by up to 2.5%.

Yes, I'm interested in a 'no-case-split' annuity option through Midland National

How do you want to receive commission payments?*

As an individualThrough a business entity
If you we'll be paying a business entity, what is the full legal name of the business?
Enter your SSN or EIN (for Payroll/1099 purposes)*
Enter SSN if you want commissions paid to you individually, or an individual or EIN if commissions are to be paid to a business entity.
What address should 1099's be sent to (business or personal):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

You have the opportunity to be featured on the "Meet Out Team" section of the velomon.com website. To do so, you will need to complete the following information
What 'Market Area' would you like to be identified with (i.e. Greater Atlanta, North Texas, etc.)
Upload a Professional Headshot Photo to use on the sited (or email one to us later)

Cancelof
Write a brief bio on yourself, your experience, hobbies, etc. (1-3 paragraphs)

By affixing your signature to this document, you are indicating your agreement with the terms of the Velomon Advisor Agreement (above) and the billing arrangement for the Membership Level selected.*

Clear
Should be Empty:

Bank information for Commission Payments