SLATE Direct Agent Intake Form

Appointment/Contracting Kit

Questions??

Please call your SLATE Support Team at 833-752-8300 ext 1.

Are You Contracting As An:*

Have your commissions paid to Entity (LLC, Corp, etc) or paid directly to You, Agent? **Assigning Commissions needs to be discussed with the SLATE Contracting Team**

First Name:*

Last Name:*

Full Name:

Personal/Enity Information

Entity Name:*

Enity NameTin #

Entity Principal:*

Personal NPN:*

This can be found at https://www.nipr.com/PacNpnSearch.htm

Entity NPN:*

Entity TIN:*

Social Security #:*

Driver's License#:*

Birth Date:*

MonthDayYear

Birth City and State:*

Gender:*

MaleFemale

Cell Phone Number:*

Area CodePhone Number

Home Phone Number:

Area CodePhone Number

Phone Number (Business):

Area CodePhone Number

Fax #:

Area CodePhone Number

E-mail Address:*

Home Address:*

Street Address

Street Address Line 2

CityState

Zip Code

Do you have a Mailing Address different then your Home Address?*

YESNO

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Previous Address for Last 10 Years:

What state do you plan on writing most of your business:*

Background Information

1) Do you have any indebtedness to an Insurance Company?*

Give name company, amount and repayment agreement.

2) Have you ever been convicted of a felony, or a misdemeanor, other than a traffic offense?*

Explain and provide dates for each occurrence.

3) Have you ever had your Driver's License revoked?*

Explain and provide dates for each occurrence.

4) Are you in process, or have you ever filed for Bankruptcy, declared bankrupt or insolvent, or had salary garnished?*

Explain and provide dates for each occurrence.

4a) Have you or any business of which you were associated or principal of been involved in a bankruptcy action or compromised liabilities with creditors?*

4b) Have you ever filed a petition for bankruptcy or for protection from creditors?*

4c) Has any insurance or securities brokerage firm with whom you have been associated ever filed a bankruptcy petition or declared bankrupt, either during your association or within 5 years after termination of such association.*

When was it filed?

Date

What was the amount of the bankruptcy?

Which was filed?

Chapter 7Chapter 11Chapter 13

What date was your bankruptcy settled?

Date

5) Are you now or have you ever been employed by, or associated with to any degree, directly, or indirectly, a bank, savings and loan or other financial institution?*

6) Are you now subject of any complaint, investigation, or proceeding which could result in a yes answer to any of thepreceding questions?*

7) Have you ever been refused a bond or Errors and Omissions Insurance?*

Explain:

8) Have you ever had your insurance license suspended or revoked?*

Explain:

9) Have you been fined or had disciplinary action taken against you with any Department of Insurance?*

Explain:

10) Are you, at present, or within the past five years, been involved in any civil litigation, judgments, liens or foreclosures?*

Explain:

11) Have you ever been denied an appointment with any insurance company?*

Explain:

12) Have you ever been terminated for cause by any insurance carrier?*

Explain:

Upload any Supporting Docs:

Browse Files

Additional Information

List a Beneficiary:*

Beneficiary Relationship:*

Have you taken an Anti-Money Laundering Course within the past 2 years?*

If yes, please provide date and name of course.

Are you Registered Rep with FINRA?*

Required Documents

1) E&O Certificate:*

Upload a File

If you havent purchased your E&O you can purchase one here with our SLATE Discount Program :

SLATE E&O Discount Program

2) BANKING INFORMATION

Voided Check

PLEASE NOTE: Name On Check Needs to Match Who Will Be Appointed

If selected Entity needs to have the ENTITY name; if Agent needs to have your name.

ALSO: MUST BE A CHECK NOT A DIRECT DEPOSIT FORM

Financial Institution:*

Bank Routing #:*

Account Number:*

Voided Check (Upload):

Browse Files

OR

Take of Photo of your Check:

2) Resident Insurance License

IF you need a copy of your License click: NIPR: License Printing by State

Personal Resident License:*

Browse Files

Entity Resident License:*

Browse Files

Non Resident States:

Upload ALL Non-Res Licenses:

Browse Files

Carrier Appointments

If uncertain which carriers to pick please reach out to us.

Medicare Carriers Requested:*

ACA / Individual Carriers Requested:*

Life Insurance Carriers Requested:

Annuity Carriers Requested:

Dental / Vision :

HumanaSpirit DentalOther

Medicare Supplement and Life product Advancing Options:*

SLATE Campaign Manager

SLATE Campaign MANAGER

SLATE strives to not only meet agent needs and expectations, but to exceed them. We are always exploring new and innovative ways to provide additional value as your partner. As such, we are excited to introduce you to our new lead management system "SLATE Campaign Manager”. This customer relationship management (CRM) will automate many touches through the lead prospecting cycle and increase efficiency. Some of the touches include text messaging, automated voicemails, emails and more. It’s a robust platform with flexibility. It can be used with managing your existing clientele as well as prospective new business. It’s provided to you at absolutely no cost! We are incurring the full cost of this CRM for all our agents nationwide. User Understanding

It is important that you understand while this system is powerful and can enhance your business, it also needs to be used properly in order to maintain compliance. This system can “automate” campaigns and actions, but it’s vital that the lead or prospect has agreed or opted into that type of action. Beyond CMS compliance, it’s especially important to follow TCPA (Telephone Consumer Protection Act) compliance when using this platform. If agents do not utilize the system properly, they may be subject to non-compliance and potential legal action. SLATE has a lead program available for agent purchase in conjunction with this platform that are compliant and who have opted in. Any lead uploaded into your CRM with automations created should have the agreed to the following disclaimer language prior: “I provide my signature giving express consent to receive marketing communications via automated telephone dialing systems, artificial or pre-recorded voices, emails, live phone calls, pre-recorded calls, postal mail, text messages via SMS or MMS, and other forms of communication regarding offers of Medicare Supplement, Medicare Advantage, Part D, or other products from and/or one or more of it’s marketing partners and affiliates and agents to the number(s) and/or email I provided including a mobile phone, even if I am on a state or federal Do Not Call and /or Do Not Email registry. The list of companies participating is subject to change. I understand my wireless carrier may impose charges for calls or texts. I understand that my consent to receive communications is not a condition of purchase and I may revoke my consent anytime”.

Terms and Conditions

Please read and agree to the below terms and conditions prior to use:

By signing below, I agree to indemnify, defend and hold harmless SLATE from and against any and all claims, liabilities, judgments, costs, damages and expenses (including reasonable attorneys’ fees) arising out of the use and/or misuse of this system.

Signature

Name

First NameLast Name

Date

Other Allignment Questions

If aligning with an Agency Partner, who?*

If Direct to SLATE (Write SLATE)

Are you currently contracted with another FMO for the above mentioned carriers? *

Please indicate by name the Carriers you are currently contracted.

STATEMENT OF UNDERSTANDING

(PLEASE READ CAREFULLY)

I hereby authorize SLATE and its affiliates ("The Authorized Parties"), to 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 electronic or paper contract submission, software and/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. Furthermore, I agree to contact by SLATE and Pinnacle Financial Services staff and applicable third party vendors via phone, email and text message as it pertains to my business related activities and indicated carriers.

By signing this form, I acknowledge that all information is true and correct to the best of my knowledge.

If you have a release from your current upline, upload here:

Browse Files

Release on Top of Hierarchy Letter Head

Signature*