Insurance Agent Enrollment

Full Name*

First NameLast Name

Social Security Number

HOME Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

MAILING ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Format: (000) 000-0000.

E-mail*

example@example.com

CURRENT EMPLOYER NAME*

CURRENT EMPLOYER BEGIN DATE*

EMPLOYMENT ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

CURRENT POSITION TITLE*

PREVIOUS EMPLOYER NAME (previous 5 years required)

Previous EMPLOYER BEGIN DATE

EMPLOYMENT ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Question 1
NOTE: For Questions 1a, 1b and 1c, "Convicted" includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea of guilty or nolo contendere or no contest, or having been given probation, a suspended sentence, or a fine.

If you answer yes to any of these questions, you must attach to this application:

a) a written statement explaining the circumstances of each incident,
b) a copy of the charging document,
c) a copy of the official document, which demonstrates the resolution of the charges or any final judgment.

Have you ever been convicted of a misdemeanor, had a judgment withheld or deferred, or are you currently charged with committing a misdemeanor? You may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, driving under the influence (DUI), driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license. You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court)*

YesNo

YesNoNot Applicable

YesNo

Have you ever been named or involved as a party in an administrative proceeding, including FINRA sanction or arbitration proceeding regarding any professional or occupational license or registration?"Involved" means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, a cease and desist order, a prohibition order, a compliance order, placed on probation, sanctioned or surrendering a license to resolve an administrative action. "Involved" also means being named as a party to an administrative or arbitration proceeding, which is related to a professional or occupational license, or registration. "Involved" also means having a license, or registration application denied or the act of withdrawing an application to avoid a denial. INCLUDE any business so named because of your actions in your capacity as an owner, partner, officer or director, or member or manager of a Limited Liability Company. You may EXCLUDE terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee. If you answer yes, you must attach to this application: a) a written statement identifying the type of license and explaining the circumstances of each incident, b) a copy of the Notice of Hearing or other document that states the charges and allegations, and c) a copy of the official document, which demonstrates the resolution of the charges or any final judgment.*

YesNo

Has any demand been made or judgment rendered against you or any business in which you are or were an owner, partner, officer or director, or member or manager of a limited liability company, for overdue monies by an insurer, insured or producer, or have you ever been subject to a bankruptcy proceeding? Do not include personal bankruptcies, unless they involve funds held on behalf of others.If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for repayment, and/or type and location of bankruptcy.*

YesNo

YesNoComment

Are you currently a party to, or have you ever been found liable in, any lawsuit, arbitrations or mediation proceeding involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty? If you answer yes, you must attach to this application: a) a written statement summarizing the details of each incident, b) a copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, or mediation proceedings, and c) a copy of the official documents, which demonstrates the resolution of the charges or any final judgment.*

YesNo

Have you or any business in which you are or were an owner, partner, officer or director, or member or manager of a limited liability company, ever had an insurance agency contract or any other business relationship with an insurance company terminated for any alleged misconduct?If you answer yes, you must attach to this application:a) a written statement summarizing the details of each incident and explaining why you feel this incident should not prevent you from receiving an insurance license, andb) copies of all relevant documents.*

YesNo

How Many Months in Arrears

YesNo

I understand that I am required to complete and submit the Georgia Citizenship Affidavit and provide a copy of an acceptable ID before this application can be reviewed or processed.I further understand that I must use required form GID276-EN, a copy of which is available on the Georgia OCI website. I have completed the form including the required notary and ID and have the scanned copy ready to attach to this application or upload into the NIPR Warehouse immediately upon submission of this application.

Please list anything that I may need to know to help the application process.

Credit Card Information for Mentorship ($295.00) [Zelle info preferred]*

Card Number

CCV

Exp MoExp Year

Postal / Zip Code

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