Contract Information and Signature Form. If contracting as a: Producer only - complete sections 1, 3 & Individual FCRA Authorization Form Business Entity only - complete sections 2 & 3 Producer Information Section 1 Business Entity & Principal- complete sections 1, 2, 3 (both signature blocks) & Individual FCRA Authorization Form (Required) Name: SSN: - - DOB First Name, Middle Initial, Last Name (as it appears on license) MM DD YYYY Home Address: Not a P.O. Box City State Zip Code Business Address: P.O. Box Accepted City State Zip Code Primary Phone Number: - - Business Phone: - - Email Address: Master General Agency (If applicable): Xxxxxxxx-Xxxxxxxx Marketing Errors & Omission Insurance (As Required): $ Carrier Name Minimum $1M Per Claim Background Information (Required - Must be answered) Yes No Has any regulatory authority, such as an insurance department, FINRA or the SEC ever fined or suspended you, placed you on probation, assessed you any administrative costs, entered into a consent order with you, issued you a restricted license, or otherwise disciplined you? Are you currently under investigation by any regulatory authority, such as an insurance department, FINRA or the SEC? Yes No Other than minor traffic offenses that did not result in harm to a person or property, have you been (1) convicted of any offense, or (2) pled guilty or nolo contendre (no contest) to any offense? NOTE: Answering “YES” to the above questions does not automatically preclude you from being contracted. If Yes, please include county Directions: PLEASE PROVIDE A WRITTEN EXPLANATION for any “YES” answer including the disposition and applicable supporting documentation (court documents, insurance department documents etc.). Failure to answer “YES”, when appropriate, may result in denial of your request to be contracted. Contracting Selection
Contract Information and Signature Form. If contracting as a: Producer only - complete sections 1, 3 & Individual FCRA Authorization Form Business Entity only - complete sections 2 & 3 WEBSITE Producer Information
