Get Contracted WithSouth Atlantic Management Step 1 of 3 - Personal Information 33% First Name*Middle Initial*Last Name*Maiden Name*Will you be applying as an individual or an agency? If you are not an agency, type N/A in the box below* Individual Agency If applying as an agency, provide a business name, tax ID, and agency NPN*Social Security Number*Driver's License Number*Driver's License State*Driver's License Expiration*Insurance License Number*Insurance License Expiration*Agent NPN*Agency Name - If you don't have an agency, type N/A in the box below*Agency NPN - If you don't have an agency, type N/A in the box below*Type of License - Health, Life, etc*Non-Resident Appointments Desired (Florida list counties)* Bank Name*Type of Account*Account Number*Routing Number*Home Street Address*City*Zip Code*State*County*Past Addresses*If different from above, please provide past 7 years of address history (Street, City, Zip Code, State, County).Business Street Address*City*Zip Code*State*Country*Cell Phone Number*Home Phone Number*Business Phone Number*Fax*Email* Date of Birth* MM slash DD slash YYYY City and State of Birth*For life/annuity, have you completed AML training?* Yes No AML training provider*AML training completion date* MM slash DD slash YYYY If you answer yes to any question, be sure to provide a detailed explanation including specific dates Years in Insurance*Other carriers that you currently represent*Highest Level of Education*Do you currently have any outstanding debit balance or vectors? Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Have you ever been charged with, convicted of, or pled guilty or no contest to any felony, misdemeanor, Federal/State insurance and/or securities or investments regulations statutes?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Have you ever been on probation?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*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?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Have you ever been alleged to have engaged in any fraud?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Has any insurance or financial services company or broker-dealer terminated your contract or appointment or permitted you to resign for a reason other than lack of sales?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Have you ever had an appointment with an insurance company terminated for cause or been denied an appointment?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Does any insurer, insured, or other person claim any commission chargeback or other indebtedness from you as a result of any insurance transactions or business?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Has any lawsuit or claim ever been made against 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?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Have you ever had an insurance or securities license denied, suspended, cancelled or revoked?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Has any state or federal regulatory body found you to have been a cause of an investment – or insurance – related business having its authorization to do business denied, suspended, revoked, or restricted?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Has any state or federal regulatory agency revoked or suspended your license as an attorney, accountant, or federal contractor?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Has any state or federal regulatory agency found you to have made a false statement or omission or been dishonest, unfair, or unethical?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Have you had any interruptions in licensing?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Has any state, federal or self-regulatory agency filed a complaint against you, fined, sanctioned, censured, penalized or otherwise disciplined you for a violation of their regulations or state or federal statutes? Have you ever been the subject of a consumer-initiated complaint?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Have you personally or any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or declared bankruptcy?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Have you ever had any judgments, garnishments, or liens against you?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Are you connected in any way with a bank, savings & loan association, or other lending or financial institution?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Have you ever used any other names or aliases?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Do you have any unresolved matters pending with the internal revenue service or other taxing authority?* Yes No If yes, explain. Be sure to provide a detailed explanation including specific dates.*Employment history for the last 7 years?* Choose the contracts you are interested in:Medicare Advantage Carriers Aetna Allwell / Centene Anthem BlueCross BlueShield SC Bright Health Cigna Healthspring Clover Health Florida Blue Humana SilverScript PDP United Healthcare Wellcare Shared Health (MS) Devoted Medicare Supplement Accendo ACE Aetna Senior Supplemental Bankers Fidelity BlueCross BlueSheild SC Central States Indemnity Cigna Supplemental CSI Life Guarantee Trust Life (GTL) Liberty Bankers Life Lumico Mutual of Omaha Shenandoah Life Thrivent Ancillary Products Aetna Senior Supplemental Assurity Bankers Fidelity Central United Life Guarantee Trust Life (GTL) Medico Spirit Dental Standard Life & Casualty SureBridge UNL Life Insurance Aetna Senior Supplemental Aflac AIG American Amicable Assurity Bankers Fidelity Banner Life Foresters Gerber Great Western Liberty Bankers Life Lumico Mutual of Omaha Oxford Life Pekin Prosperity Life Royal Neighbors Standard Life & Casualty Sons of Norway Transamerica United Home Life Washington National South Atlantic Management is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please check the checkbox below to subscribe to our email list:* I agree to receive other communications from South Atlantic Management.In order to provide you the content requested, we need to store and process your personal data. If you consent to us storing your personal data for this purpose, please check the checkbox below.* I agree to allow South Atlantic Management to store and process my personal data. You can unsubscribe from these communications at any time. Signature Authorization PLEASE READ THIS AUTHORIZATION AND SIGN IN THE CENTER OF THE SPACE BELOW. I hereby authorize South Atlantic Management and its general agency customers (the “Authorized Parties”) to affix or append a copy of my signature, as set forth to any and all required signature fields on forms and agreements of any insurance carrier (a “Carrier”) designated by me through any means, including without limitation, by email, fax, or orally. The Authorized Parties shall be permitted to complete and submit such forms and agreements on my behalf for the purpose of becoming authorized to sell Carrier Authorized insurance products. I hereby release, indemnify, and hold harmless the Authorized Parties against any and all claims, demands, losses, damages, and cause of action, including expenses, costs, and reasonable attorney’s 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 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 attorney’s fees which such third party may incur as a result of its reliance on any form of agreement bearing my signature pursuant to this authorization. I understand that I will receive a complete copy of all contracting paperwork and that my signature shall not be kept on file or used for any other purpose other than for the contracting paperwork specified below. Please write your signature in the space below.*Please attach a copy of your Insurance License.*Max. file size: 16 MB.Please attach a copy of your Driver's License.*Max. file size: 16 MB.Please attach a copy of your E&O Certification*Max. file size: 16 MB.Please attach a copy of a voided check or Direct Deposit Letter from your bank*Max. file size: 16 MB. Δ
