Carrier contract request* LEAD CONTRACT: AMERICO GERBER MUTUAL OF OMAHA NON-LEAD CONTRACT AMERICO GERBER FORESTERS MUTUAL OF OMAHA UNITED AMERICAN UNITED HOME LIFE ASSURITY WASHINGTON NATL. PHOENIX LIFE KEMPER COLUMBIAN LIFE PRINCIPAL AMERICAN NATIONAL AMERITAS AMERICAN GENERAL AMERICAN BENEFITS ASC. FIDELITY LIFE ASSOC. FIDELITY SECURITY GENWORTH ILLINOIS MUTUAL JOHN HANCOCK LINCOLN FINANCIAL MASS MUTUAL METLIFE NATIONWIDE NORTH AMERICAN PROTECTIVE PRUDENTIAL TRANSAMERICA VOYA Most carriers accept "J.I.T." (Just-in-time) contracting, and they won't process your contract until you submit a client application. * Other carriers are available, per request.
Email: CONTRACTING@FinancialGuards.com Fax: (239) 963-3133 New Agent Information Form Agent name: (As it appears on your insurance license) Address: Phone: E-mail: Social Security Number: DOB: Gender: State: Male Female License number(s): E&O carrier: Cert# Amount: Expires on: Please attach a copy of your insurance license and E&O Return by EMAIL: contracting@financialguards.com or fax (239) 963-3133
This Agent Indebtedness Agreement (this "Agreement"), effective as of the date subscribed below is entered into by and between Financial Guards, a national IMO BROKERAGE with its offices located at 4755 Tamiami Trl N# 40, Naples FL 34109 and, an individual or business (the "Agent"),including the down line hierarchy of such Agent, if any. The Agent conducts business at the address set forth under such Agent's name on the signature page of this Agreement. Financial Guards and the Agent, inconsideration of the premises and mutual covenants and agreements herein contained, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged by Financial Guards and the Agent, agree as follows: 1. Definitions. a. "Financial Guards Carrier" means any insurance company with which Financial Guards has contractually committed, either prior to or after the date of this Agreement, to recruit agents to market and sell insurance products on behalf of such insurance company and with which the Agent is not affiliated with through Financial Guards prior to the execution of this Agreement. b. Financial Guards is, and will be, a party to certain contracts with Financial Guards Carriers under which Financial Guards recruits, and will recruit, agents for such Financial Guards Carriers; c. The result of such recruiting may be a Carrier Selling Agreement; and From time to time, Financial Guards Carriers, pursuant to a Carrier Selling Agreement, may advance commissions to the Agent, charge back commissions previously paid to the Agent, lend money to the Agent or agree to other terms under which the Agent will become indebted to the Financial Guards Carrier (the "Agent Indebtedness"); d. Financial Guards may, from time to time, be asked by the Financial Guards Carrier to guarantee the Agent Indebtedness or to repay, on behalf of the Agent, the Agent Indebtedness; and Financial Guards and the Agent, in consideration of the premises and mutual covenants and agreements herein contained, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged by Financial Guards and the Agent, agree as follows: 2. Repayment of Agent Indebtedness. Financial Guards and the Agent agree that the Agent is responsible for the Agent Indebtedness (including any Agent Indebtedness arising from such Agent's down line hierarchy), that the Agent shall repay such Agent Indebtedness pursuant to the terms of the Carrier Selling Agreement or pursuant to any other agreement or arrangement between the Agent and the Financial Guards Carrier, and that in the event Financial Guards pays to the Financial Guards Carrier any amount of the Agent Indebtedness, the Agent shall reimburse Financial Guards for such amount within 30 days after receipt of notice from Financial Guards. The Agent agrees to pay all costs of collection, including attorney fees, collection agency fees of 25% incurred by Company or its successors or assigns in collecting any Agent indebtedness. 3. Independent Contractor. The Agent agrees that the Agent will perform all services under this Agreement and the Carrier Selling Agreement as an independent contractor. thing in the Agreement or in any Carrier Selling Agreement will be deemed to create an employer-employee, partnership, or joint venture relationship between Financial Guards and the Agent. 4. In the event you acquire a debit with Financial Guards, signing this agreement allows us to vector your account after 60 days delinquency. IN W ITNESS W HEREOF, each of and the Agent have executed this Agreement to be effective as of the date set forth below. 5. Photo Release: I additionally grant Financial Guards the right to take, use, adapt, modify, reproduce, transmit, display, broadcast, publish, print, and disseminate, in any manner or medium, now known or later devised, my name, image, likeness and voice (hereinafter, my Publicity Rights ), for the purpose, including but not limited to, promoting and advertising Financial Guards and its services. If you do not wish to be included in any photo, please let us know in advance and we will exclude you. 6. Fee Schedule. Account Reconciliation/Balance Assistance and Account Research $35.00 per hour. Financial Guards. By: Daniel Dragan, Chief Executive Officer AGENT: AGENCY NAME, if you are an agency principal: DATE: X Signature: Print Name: Address: (This agreement only impacts agents who may now, or eventually, owe us money, typically for chargebacks or unpaid advances. We require all licensed agents to sign this agreement; however, in most cases it will not pertain to you but still needs to be completed to work with Financial Guards.) 2015 Financial Guards
Signature Authorization PLEASE READ THIS AUTHORIZATION, SIGN IN THE BOX BELOW AND SUBMIT THIS FORM BY FOLLOWING THE INSTRUCTIONS PROVIDED ON THE COVER PAGE. I,, hereby authorize SuranceBay, LLC and its general agency customers (the Authorized Parties ) to affix or append a copy of my signature, as set forth below, to any and all required signature fields on forms and agreements of any insurance carrier (a Carrier ) designated by me through the SureLC software or through any other means, including without limitation, by e-mail or orally. The Authorized Parties shall be permitted to complete and submit all such forms and agreements on my behalf for the purpose of becoming authorized to sell Carrier insurance products. I hereby release, indemnify and hold harmless the Authorized Parties against any and all claims, demands, losses, damages, and causes of action, including expenses, costs and reasonable attorneys' fees which they may sustain or incur as a result of carrying out the authority granted hereunder. By my signature below, I certify that the information I have submitted to the Authorized Parties is correct to the best of my knowledge and acknowledge that I have read and reviewed the forms and agreements which the Authorized Parties have been authorized to affix my signature. I agree to indemnify and hold any third party harmless from and against any and all claims, demands, losses, damages, and causes of action, including expenses, costs and reasonable attorneys' fees which such third party may incur as a result of its reliance on any form or agreement bearing my signature pursuant to this authorization. Please sign in the center of the box below. Please use BLACK ink. PRODUCERIDXXX
UNIVERSAL CONTRACTING INSTRUCTIONS: 1. Please complete all requested items. 2. If Universal Contracting is returned incomplete, it will increase processing time. Please scrub the documents prior to submission. After all required documents are completed, please scan and email to REQUIRED DOCUMENTS: Complete the forms attached with all questions answered. Provide letter of explanation for any YES answered legal questions and supply additional documents. Complete Signature Authorization page. Include the EFT form and a copy of a voided check. Provide current E&O certificate. Supply a current Anti-Money Laundering (AML) training certificate. Or if completed via LIMRA, please supply a date and time: /. Provide current license(s), individual and/or corporate. Supply STATE Specific Training Certificate(s) for NAIC adopted states. (Click here for a list of NAIC Approved States.) Please te: If you are selling an Annuity, go to the Carrier website to complete the CARRIER Specific product training.
Social Security #: Email: Last Name: First Name: MI: Resident Insurance License #: State: Phone: Fax: Cell: Gender: Driver's Lic. # / State: Title: Marital Status: DB / / Maiden Name: Residential Address ( PO Boxes) Move In Date: / / Line 1: Line 2: State: Zip: Mailing Address ( PO Boxes) Start Date: / / Line 1: Line 2: State: Zip: AML Provider: LIMRA NONE OTHER Date Completed: / / If Other, Provide Certificate of Completion. Are you a Registered Rep with FINRA? If, Broker/Dealer Name: CRD #: Please list any Honors you currently hold: Doing Business As: Individual Business Entity Solicitor/LOA If DBA Solicitor/LOA, list who you are assigning commissions to: Complete the following only if DBA a Business Entity: EIN: Business Name: Website: Your Title: Phone: Fax: Principal Name: Principal Title: Email: Corporate Address ( PO Boxes) Start Date: / / City/State t Needed Line 1: Line 2: Zipcode:
History *NOTE* Attach additional info if needed Employment -- Please provide past 5 years of employment history: From: / / To: / / Company: Position: Location: From: / / To: / / Company: Position: Location: From: / / To: / / Company: Position: Location: Address History -- Please provide past 5 years of address history: *NOTE* Attach additional info if needed From: / / To: / / City/State t Needed Line 1: Line 2: Zipcode: From: / / To: / / City/State t Needed Line 1: Line 2: Zipcode: From: / / To: / / City/State t Needed Line 1: Line 2: Zipcode:
Legal Questions for Contracting and Appointment Requests Please answer the following questions. If you answer YES to any question, be sure to provide a full, detailed explanation including specfic dates. Name: 1 Have you ever been charged or convicted of or plead guilty or no contest to any Felony, Misdemeanor, federal/state insurance and/or securities or investments regulations or statutes? Have you ever been on probation? 1A Have you ever been convicted of or plead guilty or no contest to any Felony? 1B Have you ever been convicted of or plead guilty or no contest to any Misdemeanor? 1C 1D 1E Have you ever been convicted of or plead guilty or no contest to a violation of federal or stat securities or investment related regulations? Have you ever been convicted of or plead guilty or no contest to a violation of state insurance department regulations or statutes? Has any foreign government, court, regulatory agency, or exchange ever entered an order against you related to investments or fraud? e 1F Have you ever been charged with a Felony? 1G Have you ever been charged with a Misdemeanor? 1H Have you ever been on probation? 2 Have you ever been or are you currently being investigated, have any pending indictment, lawsuits, or have you ever been in a lawsuit with an insurance company? 2A Are you currently under investigation by any legal or regulatory authority? 2B Have you been under investigation by any insurance company? 2C 2D Have you ever been or are you currently involved in any pending indictments, lawsuits, civil judgments or other legal proceedings (civil or criminal)(you may omit family court). Have you ever been named as a defendant or codefendant in a lawsuit, or have you ever sued or been sued by an insurance company? 3 Have you ever been alleged to have engaged in any fraud? 4 Have you ever been found to have engaged in any fraud? 5 5A Has any insurance or financial services company or broker-dealer terminated your contract or appointment or permitted you to resign for reason other than lack of sales? Were you fired because you were accused of violating insurance or investment related statures, regulations, rules or industry standards of conduct? 5B Were you fired because you were accused of fraud or the wrongful taking of property? Failure to supervise in connection with insurance or investment related statues, regulations, 5C rules or industry standards of conduct? Have you ever had an appointment with any insurance company denied or terminated for 6 cause? Does any insurer, insured, or other person claim any commission chargeback or other 7 indebtedness from you as a result of any insurance transactions or business?
8 Has any lawsuit or claim ever been made against you, your surety company, or errors and omissions insurer arising out of your sales or practices, or, have you been refused surety bonding or E&O coverage? 8A Has a bonding or surety company ever denied, paid on or revoked a bond for you? 8B Has any Errors & Omissions (E&O) carrier ever denied, paid claims on or cancelled your coverage? 9 Have you ever had an insurance or securities license denied, suspended, cancelled or revoked? Has any state or federal regulatory body found you to have been a cause of an investment or 10 insurance related business having its authorization to do business denied, suspended, revoked, or restricted? 11 Has any state or federal regulatory agency revoked or suspended your license as an attorney, accountant, or federal contractor? 12 Has any state or federal regulatory agency found you to have made a false statement or omission or been dishonest, unfair, or unethical? 13 Have you had any interruptions in licensing? Has any state, federal or self-regulatory agency filed a complaint against you, fined, 14 sanctioned, censured, penalized or otherwise disciplined you for a violation of their regulations or state or federal statutes? 14A Has any regulatory body ever sanctioned, censured, penalized or otherwise disciplined you? 14B Has any state, federal, or self-regulatory agency filed a complaint against you, fined or sanctioned you? 14C Have you ever been the subject of a consumer initiated complaint? 15 Have you personally or any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or declared bankruptcy? 15A Have you personally filed a bankruptcy petition or declared bankrtuptcy? 15B Has any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or been declared bankrupt either during your association or within fiv years after termination of such association? e 15C Is the bankruptcy pending? 16 Are there any unsatisfied judgments, garnishments or liens against you? 17 Are you connected in any way with a bank, savings & loan association, or other lending or financial institution? 18 Have you ever used any other names or aliases? 19 Do you have any unresolved matters pending with the Internal Revenue Service or other taxing authority? If you answered any questions YES, provide an explanation that includes dates, actions, and descriptions. Attach additional paper if necessary. I attest that the information I have provided is true to the best of my knowledge. I acknowledge that if any information changes, I will notify my agency office within 5 days of such change. Further, I understand that my agency may contact me when I need to answer carrier specific questions. Signature: Date:
ELECTRONIC FUND TRANSFERS (EFT)
American Home Life Insurance Co. - Additional questions for ONLINE CONTRACTING with SureLC / Surance Bay. AGENT NAME: 1
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