Insurance Agent Application Form

INSURANCE AGENT APPLICATION FORM

Applicant Information

Full Legal Name:

Licensing and Appointment Details

State(s) of Licensure:

Lines of Authority (check all that apply):

Life Accident & Health Property Casualty Personal Lines

Errors & Omissions / Financial Responsibility

Do you currently carry Errors & Omissions (E&O) insurance? Yes No

Are you currently subject to a surety bond requirement or do you have an active bond? Yes No

Background and Disclosures

Have you ever had a license refused, suspended, revoked, or otherwise subject to disciplinary action? Yes No

Have you ever been convicted of, or pled guilty or nolo contendere to, a felony or misdemeanor involving fraud or dishonesty? Yes No

Employment and Business History

References

Designated Payee / Beneficiary for Commissions

If commissions are to be paid to an individual or entity other than the applicant, provide payee details below.

Exclusions and Acknowledgments

The applicant acknowledges that the insurer may deny or terminate appointment for reasons including, but not limited to, materially false statements on this application, failure to maintain required licenses, failure to maintain required E&O or bond coverage, criminal convictions involving fraud or dishonesty, or regulatory discipline. The applicant further acknowledges that any material misstatement may be grounds for rescission of appointment and recovery of commissions.

I acknowledge receipt of the above exclusion notice: Yes No

Declaration and Authorization

I certify under penalty of perjury that the information provided in this application is true, complete and correct to the best of my knowledge. I authorize any state insurance department, current or former employers, insurers, surety companies, and law enforcement agencies to release records and information to the insurer for the purpose of verifying the information contained herein and for use in underwriting, appointment decisions, or investigation of complaints. I understand that the insurer may obtain consumer reports, background checks, and loss history reports and that the insurer may provide relevant information to other insurers or regulatory authorities.

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