Personal Information First Name
Middle Initial
Last Name
Maiden Name
Will you be applying as an individual or an agency? YesNo
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
Agency NPN
Type of License
Non-Resident Appointments Desired (Florida list counties)
EFT Information Bank Name
Type of Account
Account Number
Routing Number
Home Street Address
City
Zip Code
State
County
If different from above, please provide past 7 years of address history (Street, City, Zip Code, State, County).
Past Addresses
Business Street Address
Cell Phone Number
Home Phone Number
Business Phone Number
Fax
Email
Date of Birth
City and State of Birth
For life/annuity, have you completed AML training? YesNo
AML training provider
AML training completion date
Background Information (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? YesNo
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? YesNo
Have you ever been on probation? YesNo
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? YesNo
Have you ever been alleged to have engaged in any fraud? YesNo
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? YesNo
Have you ever had an appointment with an insurance company terminated for cause or been denied an appointment? YesNo
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? YesNo
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? YesNo
Have you ever had an insurance or securities license denied, suspended, cancelled or revoked? YesNo
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? YesNo
Has any state or federal regulatory agency revoked or suspended your license as an attorney, accountant, or federal contractor? YesNo
Has any state or federal regulatory agency found you to have made a false statement or omission or been dishonest, unfair, or unethical? YesNo
Have you had any interruptions in licensing? YesNo
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? YesNo
Have you personally or any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or declared bankruptcy? YesNo
Have you ever had any judgments, garnishments, or liens against you? YesNo
Are you connected in any way with a bank, savings & loan association, or other lending or financial institution? YesNo
Have you ever used any other names or aliases? YesNo
Do you have any unresolved matters pending with the internal revenue service or other taxing authority? YesNo
Employment history for the last 7 years?
Choose the contracts you are interested in: Medicare Advantage Carriers AetnaAllwell / CenteneAnthemBlueCross BlueShield SCBright HealthCigna HealthspringHumanaSilverScript PDPUnited HealthcareWellcare
Medicare Supplement Aetna Senior SupplementalBankers FidelityBlueCross BlueSheild SCCentral States IndemnityCigna SupplementalCSI LifeEverestGuarantee Trust Life (GTL)Liberty Bankers LifeLumicoMutual of OmahaOxford LifeProsperity LifeShenandoah LifeThriventTransamerica
Ancillary Products Aetna Senior SupplementalAssurityBankers FidelityCentral United LifeGuarantee Trust Life (GTL)KemperMedicoSpirit DentalStandard Life & CasualtySureBridgeUNL
Life Insurance Aetna Senior SupplementalAIGAmerican AmicableAssurityBankers FidelityBanner LifeForestersGerberGreat WesternKemperLiberty Bankers LifeLumicoMutual of OmahaOxford LifePekinStandard Life & CasualtyTransamericaUnited Home LifeWashington National
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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.
Please attach a copy of your E&O Certification
Please attach a copy of a voided check.
