Flyer Life Group Contracting Profile Packet

1
Drivers License* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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2
Resident State Insurance License* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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3
AML Certificate (REGED AML ONLY ACCEPTED)* This field is required.REGED ONLY! We are not able to accept any other AML at this time.
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Select files to upload
Max. file size: 10.6MB
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4
Voided Check or EFT Bank Direct Deposit Form* This field is required.No Starter Checks or Written Forms Will Be Accepted
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Select files to upload
Max. file size: 10.6MB
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5
Error and Omissions Insurance***Not mandatory but required for several carriers and Annuity/IUL sales
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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6
Full Legal Name* This field is required.
First Name
Middle Name
Last Name
Suffix
7
Date of Birth* This field is required.
Date
Month
Day
Year
8
Social Security Number (SSN)* This field is required.
9
Gender* This field is required.
Male
Female
10
Married* This field is required.
YESNO
11
Business Email* This field is required.
example@example.com
12
Business Phone Number* This field is required.
Area Code
Phone Number
13
Current Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
Move In Date* This field is required.
Date
Month
Day
Year
15
Have you been at current address more than 3 years* This field is required.
YESNO
16
Previous Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
17
Previous Address Move In Date
Date
Month
Day
Year
18
Drivers License Number* This field is required.You will be asked to upload your license at the end of the form
19
Drivers License State* This field is required.
Please Select
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
20
Resident Insurance License Number* This field is required.
21
Resident Insurance License State* This field is required.
Please Select
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
22
Are you doing business as a* This field is required.
Individual
Business Entity
23
1. Have you ever been charged or convicted of, or pled guilty or no contest to, any felony, misdemeanor, federal/state insurance and/or securities or investments regulations or statutes?* This field is required.
YESNO
24
1a. Have you ever been convicted of, or pled guilty or no contest to, any felony?* This field is required.
YESNO
25
1b. Have you ever been convicted of, or pled guilty or no contest to, any misdemeanor?* This field is required.
YESNO
26
1c. Have you ever been convicted of, or pled guilty or no contest to, a violation of federal or state securities or investment-related regulations?* This field is required.
YESNO
27
1d. Have you ever been convicted of, or pled guilty or no contest to, a violation of state insurance department regulation or statute?* This field is required.
YESNO
28
1e. Has any foreign government, court, regulatory agency, or exchange ever entered an order against you related to income investments or fraud?* This field is required.
YESNO
29
1f. Have you ever been charged with a felony?* This field is required.
YESNO
30
1g. Have you ever been charged with a misdemeanor?* This field is required.
YESNO
31
1h. Have you ever been on probation?* This field is required.
YESNO
32
2. Have you ever been, or are you currently being investigated, have any pending indictments, lawsuits, or have you ever been in a lawsuit with an insurance company?* This field is required.
YESNO
33
2a. Are you currently under investigation by any legal or regulatory agency?* This field is required.
YESNO
34
2b. Have you been under investigation by any insurance company?* This field is required.
YESNO
35
2c. Have you ever been, or are you currently involved in any pending indictments, lawsuits, civil judgements or other legal proceedings (civil or criminal) (you may omit family court)?* This field is required.
YESNO
36
2d. Have you ever been named as a defendant or co-defendant in a lawsuit, or have you ever sued or been sued by an insurance company?* This field is required.
YESNO
37
3. Have you ever been alleged to have engaged in any fraud?* This field is required.
YESNO
38
4. Have you ever been found to have engaged in any fraud?* This field is required.
YESNO
39
5. 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?* This field is required.
YESNO
40
5a. Were you fired because you were accused of violating insurance or investment-related statutes, regulations, rules, or industry standards of conduct?* This field is required.
YESNO
41
5b. Were you fired because you were accused of fraud or the wrongful taking of property?* This field is required.
YESNO
42
5c. Failure to supervise in connection with insurance or investment-related statutes, regulations, rules, or industry standards of conduct?* This field is required.
YESNO
43
6. Have you ever had an appointment with any insurance company denied or terminated for cause? (If you have been reported to Vector One, answer YES)* This field is required.
YESNO
44
7. 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? (If you have been reported to Vector One, answer YES)* This field is required.
YESNO
45
8. 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?* This field is required.
YESNO
46
8A. Has a bonding or surety company ever denied, paid on, or revoked a bond for you?* This field is required.
YESNO
47
8B. Has any Errors & Omissions company ever denied, paid claims on, or cancelled your coverage?* This field is required.
YESNO
48
9. Have you ever had an insurance or securities license denied, suspended, cancelled, or revoked?* This field is required.
YESNO
49
10. Has any state or federal regulatory body found you to have been a cause of an investment or insurance-related business having its authorization to do business denied, suspended, revoked, or restricted?* This field is required.
YESNO
50
11. Has any state or federal regulatory agency revoked or suspended your license as an attorney, accountant, or federal contractor?* This field is required.
YESNO
51
12. Has any state or federal regulatory agency found you to have made a false statement or omission or been dishonest, unfair, or unethical?* This field is required.
YESNO
52
13. Have you ever had any interruptions in licensing?* This field is required.
YESNO
53
14. 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 statuses?* This field is required.
YESNO
54
14A. Has any regulatory body ever sanctioned, censured, penalized, or otherwise disciplined you?* This field is required.
YESNO
55
14B. Has any state, federal, or self-regulatory agency filed a complaint against you, fined, or sanctioned you?* This field is required.
YESNO
56
14C. Have you ever been the subject of a consumer-initiated complaint?* This field is required.
YESNO
57
15. Have you personally, or any insurance or securities brokerage firm with whom you have been associated, filed a bankruptcy petition, or declared bankruptcy?* This field is required.
YESNO
58
15A. Have you personally filed a bankruptcy petition or declared bankruptcy?* This field is required.
YESNO
59
15B. Has any insurance or securities brokerage firm, with whom you have been associated, filed a bankruptcy petition, or been declared bankrupt, either during your association with them or within 5 years after termination of such an association?* This field is required.
YESNO
60
15C. Is the bankruptcy pending?* This field is required.
YESNO
61
16. Are there any unsatisfied judgements or liens against you?* This field is required.
YESNO
62
17. Are you connected in any way with a bank, savings & loan association, or other lending or financial institution?* This field is required.
YESNO
63
18. Have you ever used any other names or aliases?* This field is required.
YESNO
64
19. Do you have any unresolved matters pending with the Internal Revenue Service, or other taxing authority?* This field is required.
YESNO
65
Signature* This field is required.I attest that the information I have provided is true to the best of my knowledge. I acknowledge that if any information changes, I will notify my agency office within 5 days of such change. Further, I understand that my agency may contact me when I need to answer carrier-specific questions.
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66
Please read this page and click next to apply your signature to the following page to be applied
67
Signature Authorization* This field is required.PLEASE READ THIS AUTHORIZATION, SIGN IN THE BOX BELOW AND SUBMIT THIS FORM BY FOLLOWING THE INSTRUCTIONS PROVIDED ON THE COVER PAGE. I hereby authorize SuranceBay, LLC and its general agency customers (the “Authorized Parties”) to affix or append a copy of my signature, as set forth below, to any and all required signature fields on forms and agreements of any insurance carrier (a “Carrier”) designated by me through the SureLC software or through any other means, including without limitation, by e-mail or orally. The Authorized Parties shall be permitted to complete and submit all such forms and agreements on my behalf for the purpose of becoming authorized to sell Carrier insurance products. I hereby release, indemnify and hold harmless the Authorized Parties against any and all claims, demands, losses, damages, and causes of action, including expenses, costs and reasonable attorneys' fees which they may sustain or incur as a result of carrying out the authority granted hereunder. By my signature below, I certify that the information I have submitted to the Authorized Parties is correct to the best of my knowledge and acknowledge that I have read and reviewed the forms and agreements which the Authorized Parties have been authorized to affix my signature. I agree to indemnify and hold any third party harmless from and against any and all claims, demands, losses, damages, and causes of action, including expenses, costs and reasonable attorneys' fees which such third party may incur as a result of its reliance on any form or agreement bearing my signature pursuant to this authorization. Please sign in the center of the box below.
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