Reliance Standard Appointment

Compensation Payable To:

Individual (Complete all sections except Section II)

Corporation (Complete all sections of the form)

Section I - Individual

First Name

Middle Initial

Last Name

Home Address

City

State

Zip

SS#

Date of Birth

Email Address

Please only enter a single email address.

Cell Phone #

Home Phone #

Fax #

Section II - Corporation

Corporate Officer Name

Corporation Name

Phone

Tax Class

Tax ID

Address

City

State

Zip

Resident License State

License #

National Producer #

Section III - Business Experience

Please enter 3 years of insurance related experience.

Employer #1 Name

City

State

Position

Start Date

End Date

Employer #2 Name

City

State

Position

Start Date

End Date

Employer #3 Name

City

State

Position

Start Date

End Date

It is OK to contact your present employer/carrier?

Bank Information (Direct Deposit)

NOTE: Checks or direct deposit will need to accrue to a total of $5 before the commissions are issued. Monthly commission statements will be mailed to agents (not issued electronically.)

Depository Name

Branch

Address

City

State

Zip Code

Account Type

Checking

Savings

Account Number

Bank Transit Number/ABA Number

1. Has any claim been made against you, your surety company or E&O Insurer arising out of your activities?

Yes

Please explain this:

2. Are you in debt to any insurance company and/or agency?

Yes

Please explain this:

3. Have you ever had any insurance agent, broker, or professional license revoked or suspended?

Yes

Please explain this:

4. Have you ever been fined, had an administrative action, suspension of license or otherwise been reprimanded by any licensing authority for any of the licenses you've listed above?

Yes

Please explain this:

5. Have you ever had a complaint filed against you by a state insurance department?

Yes

Please explain this:

6. Have you ever been insolvent or filed suit for bankruptcy?

Yes

Please explain this:

7. Are any collection accounts, judgments, liens or suits pending against you?

Yes

Please explain this:

10. Have you ever been convicted of a crime involving dishonesty or breach of trust?

Yes

Please explain this:

11. Have you ever been convicted of a violation of 18 USCA - 1033 (Crimes by or affecting persons engaged in the business insurance whose activities affect interstate commerce?)

Yes

Please explain this:

12. Have you ever been known by another name (alias a.k.a.) other than the name you have indicated on this application?

Yes

Please explain this: