Pivot Appointment

Applicant Information

Title

First Name

Middle Initial

Last Name

Nickname

Home Address

City

State

Zip

County

Social Security Number

Date of Birth

Cell Phone

Home Phone

Email Address

Please only enter a single email address.

National Producer #

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

Your Title

Business Address

Business City

Business State

Business Zip

Business County

Business Tax ID

Business Website

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

County

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

Name as it appears on Account

Address

City

State

Zip

Phone

Account Type

Checking

Savings

Account Number

Routing Number

Additional Information

Please indicate the appointment(s) being requested: (at least one)

State

Are you a resident?

Yes No

License Number

Attach License File

State

Are you a resident?

Yes No

License Number

Attach License File

State

Are you a resident?

Yes No

License Number

Attach License File

Please also attach E&O

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

1. Have you been appointed or contracted with Companion Life in the past?

Yes

Please explain this:

2. Have you ever been convicted of, or are currently under indictment for, any criminal felony or misdemeanor?

Yes

Please explain this:

3. Have you ever been cited, fined, placed on probation, had your licensed suspended or revoked, or paid administrative penalties, entered into a consent order, been issued a restrictive license or otherwise been disciplined or reprimanded or are you currently under investigation by any insurance department or other regulatory authority?

Yes

Please explain this:

4. Have you ever been convicted of a felony, had a judgment withheld or deferred, or are you currently charged with committing a felony, or convicted of a misdemeanor, had a judgment withheld or deferred, or are you currently charged with committing a misdemeanor?

Yes

Please explain this:

5. 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:

6. 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:

7. 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:

8. Omitted

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

Yes

Please explain this:

10. Have you ever been discharged or permitted to resign from your employment because you were accused of violating investment-related or insurance-related statutes, regulations, rules, or industry standards of conduct?

Yes

Please explain this:

11. Have you ever been discharged or permitted to resign from your employment because you were accused of fraud or the wrongful taking of property?

Yes

Please explain this:

12. Have you ever been discharged or permitted to resign from your employment because you were accused of violating company rules?

Yes

Please explain this:

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

Yes

Please explain this:

14. 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:

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

Yes

Please explain this:

16. Are you now licensed? (submit copy above)

Yes

Please enter the State(s) & License Number(s) as well as Type of License/Lines:

17. Has any state ever taken administrative action against your license?

Yes

Name state and provide details:

18. Have you ever been refused bond?

Yes

Please explain this:

19. Do you have an open Bankruptcy?

Yes

Please explain this:

20. The Violent Crime and Control Act of 1994 makes it a criminal offense for anyone who has been convicted of any criminal felony involving dishonesty or a breach of trust to willfully engage in the business of insurance. Have you ever been convicted of a felony?

Yes

Give specifics to charge, date, jurisdiction and outcome:

21. Do you now have any tax liens, judgments or garnishments?

Yes

Please explain this:

22. Are you presently indebted to any insurance company or agency?

Yes

Please explain this:

23. Are you currently covered by errors and omissions insurance?

Yes

Please enter Carrier, Limits, Policy Number and Effective/Expiration Dates:

24. Have you ever filed an errors and omissions claim?

Yes

Please explain this: