Part One: Agent Information
First Name
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Middle Initial
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Last Name
*
Address (as registered with the state)
*
City
*
State
*
Zip Code
*
Will you be contacting as
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Individual
Business Entity
If Business Entity, please provide EIN #
Cell Phone
*
By completing this form, I consent to receive emails, phone calls or text messages from representatives of Joe Ciaccio, Ciaccio Crew, C & F Insurance Group, and Advanced Health Group / AHG at the telephone number above, including my wireless, office and home numbers if provided, message and data rates may apply. I understand that my consent to receive communications in this way is not required as a condition of purchasing any goods or services.
Business Phone
Email
*
Social Security #
*
DOB
*
Gender
*
License Type
*
Life Only
Life & Health
Other
Insurance License #
*
Resident State
*
Non-Resident Licenses
Part Two: Background Questions
1.) Have you ever been charged or convicted of or plead guilty or no contest to any Felony, Misdemeanor, Federal/State Insurance and/or Securities or Investments regulations and statutes? Have you ever been on probation?
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Yes
No
2.) Have you ever been or are you currently being investigated, have nay pending indictments, lawsuits, or have you ever been in a lawsuit with an insurance company?
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Yes
No
3.) Have you ever been alleged to have engaged in any fraud?
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Yes
No
4.) Have you ever been found to have engaged in any fraud?
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Yes
No
5.) Has any insurance or financial services company or broker-dealer terminated your contact or appointment or permitted you to resign for reason other than lack of sales?
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Yes
No
6.) Have you ever had an appointment with any insurance company terminated for cause or been denied an appointment?
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Yes
No
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?
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Yes
No
8.) Has any lawsuit or claim ever been made against 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?
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Yes
No
9.) Have you ever had an insurance or securities license denied, suspended, cancelled or revoked?
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Yes
No
10.) Has any state or federal regulatory body found you to have been a cause of investment OR insurance-related business having its authorization to do business denied, suspended, revoked, or restricted?
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Yes
No
11.) Has any state or federal regulatory agency revoked or suspended your license as an attorney, accountant, or federal contractor?
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Yes
No
12.) Has any state or federal regulatory agency found you to have made a false statement or omission or been dishonest, unfair, or unethical?
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Yes
No
13.) Have you ever had interruptions in licensing?
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Yes
No
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 statutes? Have you ever been the subject of a consumer-initiated complaint?
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Yes
No
15.) Have you personally or any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or declared bankruptcy?
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Yes
No
16.) Have you ever had any judgements, garnishments or liens against you?
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Yes
No
17.) Are you connected in any way with a bank, savings & loan association or other lending or financial institution?
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Yes
No
18.) Have you ever used any other names or aliases?
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Yes
No
19.) Do you have any unresolved matters pending with the Internal Revenue Service or other taxing authority?
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Yes
No
If you answered "Yes" to any of the above questions please list the question(s) number as well as an explanation with dates in regards to all question(s) that apply
Part Three: Carriers
If you're unfamiliar with our carriers or products, please contact the office at (813) 988-3200. Ex: What UL or IUL company should I pick?
Final Expense, Mortgage Protection, Term, Annuities & Stand Alone Accidental
American Amicable
American Home Life
Assurity
Athene
Atlantic Coast Life
CICA / Citizens
Corebridge / AIG
CVS Life Insurance
EquiTrust
F&G
Foresters
Gerber Life
Guaranteed Trust Life / GTL
Kansas City Life
Liberty Bankers
Lifeshield
Lincoln Financial
Mutual of Omaha
National Life / LSW (Fully Medically Underwritten Term & UL, Annuities)
Nationwide
Pacific Life
Royal Neighbors of America / RNA
SBLI
Sentinel Life
Transamerica Life
United Home Life
Under 65 Health Insurance (not ACA / Obamacare)
LifeX
AllState
Enroll Prime
Flex Benefits
Iron Health
Transparent Price Rx
Medicare Supplements, MAPDs & Ancillaries
Aetna (MAPD / Med Supps / Hospital Indemnity)
Aetna (Med Supps)
Alignment (MAPD)
Anthem -Nationwide
BayCare - FL Only (MAPD)
Capital Life (Med Supps)
Care Plus - FL Only (MAPD)
Cigna - Nationwide (MAPD / Med Supps / Part D)
CVS (Med Supps / Hospital Indemnity / Cancer)
Devoted - FL Only (MAPD)
Florida Blue - FL Only (MAPD)
Freedom / Optimum - FL Only (MAPD)
Guaranteed Trust / GTL (Hospital Indemnity / Cancer)
Humana (MAPD / Med Supps / Part D)
Liberty Bankers (Hospital Indemnity)
Medico (Hospital Indemnity)
Mutual of Omaha / United of Omaha (Med Supps / Cancer / Critical Illness)
SCAN (MAPD)
Silver Script (Aetna's Part D)
Ultimate - FL Only (MAPD)
United Healthcare / AARP (MAPD, Med Supps & Part D)
Wellcare (MAPD / Part D)
Part Four: Additional Information
Upload copy of a Void Check
Browse Files
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of
Upload a copy of E&O
Browse Files
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of
AML Training Certificate / LIMRA Screenshot
Browse Files
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of
If others, please list
Permission
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