Companion Life Appointment

Applicant Information

Title

Mr.

Ms.

Mrs.

First Name

Middle Initial

Last Name

Nickname

Home Address

City

State

Zip

County

Social Security Number

Date of Birth

Email Address

Please only enter a single email address.

National Producer Number

Don't know your NPN? Click here to search.

Agency Information

Business Name

Business Phone

Business Fax

Business Email

Please only enter a single email address.

Business Tax Class

Business Address

Business City

Business State

Business Zip

Business Tax ID

Preferred Mailing Address

Send Correspondence to:

Business Address

Home Address

Assignment of Commission

Are you assigning your commission to an agency?

Yes

Assignee Information

Agency Name

Tax ID#

Tax Class

Address

City

State

Zip

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.)

Financial Institution

Account Type

Checking

Savings

Account Number

Routing Number

NOTE: Please upload applicable license files and E&O file. Contracting will not be processed without these additional forms.

2. Have you ever been convicted of, or currently charged with, any felony involving dishonesty or breach of trust?

Yes

3. Have you ever been convicted of, or currently charged with, commiting a crime involving moral turpitude since becoming licensed?

Yes

4. With the exception of credit life and disability insurance agents, are you employed by or associated with any degree, directly or indirectly, a financial institution as defined in section 626.988, F.S.?

Yes

5. Have you ever been convicted of any crime under the Violent Crime Control and Law Enforcement Act of 1994 (18 United States Code, §§1033 and 1034)?

Yes

7. Have you ever been bankrupt or insolvent, either personally or professionally?

Yes

8. Has an insurance company ever canceled a contract with you for any reason other than lack of production?

Yes

9. Have you ever had a complaint filed against you by a state or provincial insurance department?

Yes

10. Have you ever had an insurance license denied or revoked by a state or province?

Yes