Renaissance Appointment

Agent Information

First Name

Middle Initial

Last Name

Social Security Number

Date of Birth

Gender

Male

Female

Home Information

Address

City

County

State

Zip

Phone Number

Fax Number

Business Information

Address

City

County

State

Zip

Phone Number

Fax Number

Tax Class

Email Address

Please only enter a single email address.

Working with GA?

Please enter the General Agency Name.

Appointment and Commission Payment

Commission Payable To:

Agent

Agency

Agency Information

Name

Address

City

County

State

Zip

TIN#

Tax Class

Status

Bank Information (Direct Deposit)

Name on account

Financial Institution

City

County

State

Account Type

Checking

Savings

Routing Number

Account Number

Additional Information

1. Provide the state(s) in which you wish to be appointed

Attach License File 1

Attach License File 2

Attach License File 3

NOTE: Please upload applicable license files for selected states above.

1. Have you pled guilty or nolo contendere to or been found guilty of a felony or a crime involving moral turpitude since becoming licensed for health insurance?

Yes

Please explain this:

2. Have you, or has any corporation, partnership, association, or firm in which you were a director, officer, shareholder or partner, ever been the subject of any administrative, or legal action filed by a state insurance department; or any action filed on behalf of any state, or by the federal government based on alleged violation of state or federal insurance laws?

Yes

Please explain this:

3. Has your insurance license ever been suspended, revoked, or terminated, or have you ever been the subject of any administrative or legal action filed by a state insurance department?

Yes

Please explain this:

4. Do you maintain errors and omissions and general liability insurance coverage?

Yes

Please explain this:

5. Are there any outstanding or pending judgments or liens (including state or federal tax liens) against you?

Yes

Please explain this:

6. Have you ever been discharged or permitted to resign from your employment because you were accused of:

a. violating investment-related or insurance-related statutes, regulations, rules, or industry standards of conduct?

Yes

Please explain this:

b. fraud or the wrongful taking of property?

Yes

Please explain this:

c. violating company rules?

Yes

Please explain this:

7. Do you have any outstanding unpaid indebtedness to an insurance company or general agent?

Yes

Please explain this:

8. Within the past 10 years, have you ever had a complaint filed against you that resulted in a fine, penalty, cease or desist order, censure or consent order?

Yes

Please explain this:

9. Within the past 5 years, have you ever initiated bankruptcy proceedings or been declared bankrupt?

Yes

Please explain this: