Payment Setup & Background Check

Payment Setup & Background Check
Name (Must match what is on your license with NIPR)

First NameLast Name
Please enter the states you want to be appointed in:
Banking Direct Deposit

Please provide Banking Information for Direct Deposit from the carriers
Banking Institution:
Account Number:
Routing Number:
Account Type
Ownership Type
W-9

Please provide W-9 Information for the carriers
1. Name (as shown on your income tax return)
2. Business name, if different from above
3. Federal tax classification
Taxpayer Identification Number (TIN)
Social Security Number or Employer identification number
Please Upload a copy of W9 and Voided Check/Bank Letter

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Background Check Questionnaire

Please fill out the questionnaire for the carriers background questions
Have you ever had an insurance or securities license denied, suspended, canceled, or revoked?
Has any state, federal, or self-regulatory agency ever filed a complaint against you, or fined, sanctioned, censured, penalized, or otherwise disciplined you for violating their regulations or state or federal statutes?
Have you ever been convicted of, or pleaded guilty or nolo contendere (no contest) to, a felony? This includes having served probation, paid fines or court costs, had charges dismissed through first offender or deferred adjudication programs, received a suspended sentence, or having any FELONY charges currently pending against you?
In the past 7 years, have you been convicted of, or pleaded guilty or nolo contendere (no contest) to, a misdemeanor (other than a minor traffic violation)? This includes having served probation, paid fines or court costs, had charges dismissed through first offender or deferred adjudication programs, received a suspended sentence, or having any misdemeanor charges currently pending.
Are you currently involved as a party in any litigation or under investigation by any authority?
Have you ever had an appointment with another insurance company denied or terminated for cause?
Have you ever been involuntarily terminated or allowed to resign from employment, or from an agent or representative appointment with any insurance or financial services company, for reasons other than lack of production?
Has a bonding, surety, or E&O provider ever denied your application or claim, made a payment on your behalf, or terminated your coverage?
Are you currently delinquent on any personal or business financial obligations? Do any insurance or financial services companies hold claims against you for commission debit balances? Are there any outstanding judgments, liens, claims, or delinquent tax obligations against you?
Have you or any business in which you are or were an owner, partner, officer, or director ever filed for bankruptcy?
Medicare Agent

Contracting Request
Agent Type
Preferred Name
Email (Please use email you wish to receive contracting link requests)
example@example.com
Social Security Number
Date of Birth

MonthDayYear
Date
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
NPN
Department of Insurance License Number
Driver License Number
If you do not have a DL, please use State ID Number
Driver License State
If you do not have a DL, please use State ID
Please select carriers you wish to contract with:
Please list any additional state licenses you need in order to be contracted.
Please provide the state and license number.
Please upload a copy of your insurance License and AHIP certification, if you have not already sent them to admin@mynsip.com

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Authorization
Signature
Should be Empty:

Payment Setup & Background Check

Banking Direct Deposit

W-9

Background Check Questionnaire

Medicare Agent