New Agent Contracting Form

New Agent Contracting Form

Fill this form out with your information to start the onboarding and contracting process. Once this form is submitted continue back to the contracting page. (found back on the contracting page) Summit Wealth Consulting INTERNAL USE ONLY.
Name

First NameLast Name
Email
example@example.com
Date of Birth
MM/DD/YYYY
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
We will need your Social Security Number. (please provide below the best way to receive this information.)
Best way for GamePlan Benefits to collect your SSN
NPN# (national producer number)
Your Answer
Number of Non-Resident State Licenses
FINAL EXPENSE TELESALES CARRIER CONTRACTS: (select all available carriers)

Other/None
CARRIER ANNUITY CONTRACTS AVAILABLE (after first sale more carriers available). SELECT CARRIERS YOU WANT TO CONTRACT WITH

Other/None
CARRIER LIFE CONTRACTS AVAILABLE: (after first sale more carriers available) SELECT CARRIERS YOU WANT TO CONTRACT WITH

Other/None
CARRIER IUL/IBC CONTRACTS AVAIABLE: SELECT CARRIERS YOU WANT TO CONTRACT WITH

Other/None
CARRIER HEALTH CONTRACTS AVAILABLE: SELECT ONES YOU ARE INTERESTED IN.
Which do you hold an active License? Select all that apply
Which states do you hold an active license for the above? (list all writing business in)
List ALL: States actively writing business
What lead sources do you currently work? Select all that apply
Name of your manager? (offering you the contracts)
Manager First and Last Name
NOTES: Anything that would help our Hiring/Contracting team. If you have written any business in the last 6 months with any of the carrier's you would like to contract with please list here as well. (you may need a release)
Notes that may help our team
Should be Empty: