Argus Appointment

Applicant Information

First Name

Middle Initial

Last Name

Home Address

City

State

Zip

Social Security Number

Date of Birth

Home Phone Number

Cell Phone Number

Email Address

Please only enter a single email address.

Agency Information

Business Name

Business Phone Number

Email Address

Please only enter a single email address.

Tax ID #

Address

City

State

Zip

Names and Titles of all officers

Years at this Address

Years in Business

Assignment of Commission

Commissions are to be paid/assigned to:

Agent

Agency

Assignee Information

Name of Person Responsible

Tax ID #

Mailing Address

City

State

Zip

Bank Information (Direct Deposit)

Name on account

Financial Institution

Branch Name (if applicable)

City

State

Zip

Account Type

Checking

Savings

Routing Number

Account Number

Select the states in which you would like to be appointed. Please provide your license numbers for each respective state.

NOTE: If you are licensed and wish to sell in PA, you must be appointed prior to solicitation.

Attach Errors & Omissions Insurance

NOTE: Errors & Omissions Insurance is required to complete your application. If you are unable to upload the summary page of your E&O there are a couple options: This can either be sent by email to Carrissa@DirectBenefits.com or by fax to (651) 649-3502.

been appointed by National Guardian Life Insurance Company?

Yes

had a complaint filed against you with an Insurance Department?

Yes

been the subject of any investigation or proceeding by any insurance jurisdiction?

Yes

had any agency contract or company appointment canceled for cause (e.g., misrepresentation, misappropriation, etc.)?

Yes

been suspended, expelled, fined, barred, censured or otherwise disciplined or found to have violated any law or rule by any party in the insurance industry?

Yes

been refused a license to sell insurance or membership in any insurance organization or had a license suspended or revoked for cause by any jurisdiction?

Yes

withdrawn any application or surrendered any license to avoid any disciplinary action or the denial of a license?

Yes

been convicted of or pleaded no contest to any felony or misdemeanor, except for traffic offenses? If yes, please give complete information. You may be asked to provide a copy of the court order.

Yes

gone through bankruptcy, had salary attached or had any liens or judgments outstanding against you?

Yes

Are you presently indebted to any insurer or any insurance company or managing general agent?

Yes

Do you intend to sell insurance principally for the purpose of placing insurance on risks owned or controlled by you, your employer or your family?

Yes