Please complete the form below. Once you submit this information, you will be presented with your completed application.
*** Please Print, Sign and fax or mail it back to us in order to complete your application process. ***
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AGENT INFORMATION
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What is your gender?:
Male
Female |
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Date of Birth:
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Social Security Number:
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Are you a U.S. citizen?:
YES
NO |
If you answered NO, please provide details on how you
are approved to work in the U.S. such as: a resident
alien number or a Visa number, the terms of your stay,
and any other relevant information:
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Drivers' License Number and State Issued:
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List at least 2 Beneficiaries and their relationship to you (to receive outstanding commissions in case of death):
First:
Second: |
Mother's Maiden Name?:
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Marital Status:
Single
Married
Divorced |
What is your maiden name (if applicable)?:
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Please tell us who referred you:
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If you have a nickname that you prefer to be called, please enter it here:
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What type of contract are you requesting?:
Individual
Agency
License Only
Select Individual if: the commissions begin paid to you are reported to the IRS with your Social Security Number (SSN)
Select Agency if: the commissions being paid to you, as a signing Officer, are reported to the IRS with your Business Name and Federal Employer Identification Number (FEIN).
Select License Only if: the commissions you earn are being paid to another person or entity
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If you have chosen to be contracted as an agency, what type of agency do you represent?:
Corporation
Partnership
LLC |
Agency's license number (if applicable):
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Agency Name (Legal Entity if applicable):
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Tax ID/FEIN (if assigning commissions to agency):
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Are you a signing officer or otherwise have the ability to act as a representative of the Agency?:
YES
NO |
What is your title within your Agency?:
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What State is the entity incorporated in or registered in?:
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What year was the entity incorporated or originally registered?:
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What COUNTY is your business in?:
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Are you licensed in your Resident State? If yes, list state, license number & expiration date:
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Non-Resident License State(s):
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Do not enter licenses for states that you do not wish to be contracted in. |
Do you use a name other than your own for your insurance business (DBA)?:
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Are you ready to submit New Business now? If yes, list carrier:
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| Do you currently have E&O coverage?:
YES
NO |
Name of E&O Carrier:
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E&O Policy Number:
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Dollar amount of your E&O coverage:
Per Claim Amount:
$
Aggregate Amount:
$ |
E&O Effective Date: (mm/dd/yy)
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E&O Expiration date: (mm/dd/yy)
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INSURANCE LICENSE INFORMATION
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State:
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License No.:
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| Resident or Non-Resident:
Resident
Non-Resident |
Effective Date: (mm/dd/yy)
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Expiration date: (mm/dd/yy)
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RESIDENCE INFORMATION
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Current Residence Address (street address):
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County:
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Residence Phone:
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Cell Phone:
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Month/Year you moved in (mm/yy):
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If you have lived at your current residence for less than 10 years, please provide your previous residence(s) information.
Month/Year Moved In, Street Address, City, State, Zip:
1.
2.
3.
4.
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| Are you currently a member of NAIFA (formerly NALU)?:
YES
NO
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Please check any professional designations you have:
CEBS
CFC
CFP
CLU
CPA
CPCU
FLMI
JD
LLIF
LUTCF
MSFS
NQA
NSAA
RFP
RHU
RIA
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BUSINESS INFORMATION
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Business Street Address:
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City:
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State:
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Zip:
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City:
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State:
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Zip:
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Business Email:
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Business Phone:
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Business Fax:
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Indicate your preferred mailing address:
Street Address
Mailing Address |
| How do you prefer to be contacted?:
Phone
Mail
Email
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CARRIER SELECTION *Carriers require E&O
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Company:
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Submitting New Business?:
YES
NO
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Company:
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Submitting New Business?:
YES
NO
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Company:
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Submitting New Business?:
YES
NO
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Company:
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Submitting New Business?:
YES
NO
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Company:
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Submitting New Business?:
YES
NO
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ANTI-MONEY LAUNDERING TRAINING
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| Do you certify that you have completed the necessary Anti-Money Laundering Training?:
YES
NO
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Title of Anti-Money Laundering training program:
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Date Anti-Money Laundering training was completed:
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Do you certify that you have completed the necessary Anti-Money Laundering Training?:
YES
NO
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Anti-Money Laundering Training was delivered by (Complete all that apply):
Vendor:
Insurance Company:
Broker Dealer:
Bank:
Other:
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BACKGROUND INFORMATION
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Have you ever been charged, convicted, or plead no contest (nolo contendere) to any crime or are there criminal charges pending against you or a business with which you are connected?:
YES
NO
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Have you had or do you currently have any outstanding collection accounts, judgments, liens, or garnishments against you or a business of which you were or presently are a principal or have you been party to or are currently a party to any lawsuit, arbitration, or civil litigation?:
YES
NO
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Have you ever been a party to or have you personally violated any securities or commodities law or rule set by any securities or commodities regulatory body, organization, or employer in the commodities or insurance industry?:
YES
NO
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Do you or an organization you have been associated with owe money to any insurance company, financial institution, agency, manager, government regulatory body, or broker dealer, or have any business or personal debts that resulted in collections or charge-offs or have you ever been short in accounts with any employer?:
YES
NO
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Have you or a firm in which you were a partner, officer, or director filed for protection from creditors, been declared bankrupt or insolvent, been party to a bankruptcy or receivership proceeding, compromised liabilities with creditors, or had a direct payment procedure initiated under the Securities Investor Protection Act?:
YES
NO
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Have you ever defaulted on a promissory note, or any other debt, including consumer or credit card debt?:
YES
NO
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Have you ever been bonded?:
YES
NO
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Are you currently bonded?:
YES
NO
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Has a bonding or surety company ever denied, refused, paid out on, canceled, revoked, or refused to continue a bond for you?:
YES
NO
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Is there any reason you cannot secure a bond?:
YES
NO
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Has any insurance department, securities broker-dealer, government agency, or self-regulatory authority ever denied, suspended, revoked, censured, barred your license (as an insurance agent, attorney, accountant, or federal contractor) or registration, disciplined you with fines, entered an order against you, restricted your activities, canceled any contract or appointment with you or any member, partner, officer, or controlling persons in your organization or is there any pending disciplinary action?:
YES
NO
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Have you ever had a claim filed against your Professional Liability or Errors and Omissions insurance coverage or has any E&O Carrier denied, paid claims on, or canceled your coverage?:
YES
NO
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Have you had any complaints or deficiency claims filed against you by any insured/annuitant with any insurance company or state insurance department in the past 10 years?:
YES
NO
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Have you ever used any other names or aliases or used one on a license or other registration?:
YES
NO
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Are you now or have you ever been employed by, or associated with to any degree, directly or indirectly, a bank, savings and loan or other financial institution?:
YES
NO
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Are you now subject of any complaint, investigation, or proceeding, which could result in a yes answer to any of the preceding questions?:
YES
NO
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Last Employment
Business Name:
Title:
Manager Name:
Dates Employeed:
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Basic Education
High School Name:
City:
State:
Date of Graduation:
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Higher Education
College Name:
City:
State:
Date of Graduation:
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Please note: You may be contacted by BackNine Insurance to answer additional questions that are specific to the Carriers that you request appointment with.
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AGENT INFORMATION
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Are you now or have you ever been employed by, or associated with to any degree, directly or indirectly, a bank, savings and loan, or other financial institution?:
YES
NO
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If you have a felony conviction, have you applied for a waiver as required by 18 USC 1033?:
YES
NO
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If so, was the waiver granted?:
YES
NO
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Have you been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is not the subject of repayment agreement?:
YES
NO
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If yes, please identify the jurisdiction:
YES
NO
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Do you have a child support obligation in arrearage?:
YES
NO
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If yes, how many months are you in arrearage?:
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Are you the subject of a child support related subpoena or warrant?:
YES
NO
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Are you now the subject of any complaint, investigation, or proceeding which could result in a yes answer to any of the preceding questions?:
YES
NO
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OTHER INFORMATION
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Please type in a user name and password:
Username:
Password:
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Special Instructions:
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I affirm that the information I have submitted through the interview process to BackNine Insurance is correct to the best of my knowledge and acknowledge that I have read and reviewed the documents for which I am authorizing my signature be affixed to. I acknowledge and agree to indemnify and hold harmless any third party from and against any and all loss arising out of its reliance and acceptance of a facsimile of my signature.
Please submit your Application and follow the instructions on the following page to print and sign your application.
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