CI339A 7-04
CONSECO MARKETING, LLC
CONTRACT APPLICATION
Please check applicable company(ies):
Conseco Insurance Company (CIC)
Conseco Health Insurance Company (CHIC)
Conseco Life Insurance Company (CLIC)
TYPE OR PRINT ALL INFORMATION CLEARLY AND FAX TO 818-881-6973
Name:
Alias/Other Names:
Social Security #:
Appointment Type:
Individual
Corporate Tax ID:
Corporation Name:
Birth Date:
Mailing Preference:
Home
Business
Home Address:
Business Address:
City:
State:
Zip:
City:
State:
Zip:
Home Phone:
Business Phone:
Fax Number:
E-Mail:
For which states do you wish non-resident appointments?
(attach copy of current licenses; fees required for non-resident appointments for health life and annuity companies. Resident appointment fees required for health companies.)
Errors and omissions coverage?
Yes or
No If yes, please provide name of carrier and amount:
BACKGROUND – Please provide a complete explanation of any “yes” answers on a separate sheet:
1. Have you ever had your insurance license or securities license suspended or revoked or have you ever had any application
for an insurance license denied by any insurance department?
Yes or
No
2. Have you ever pled guilty or nolo contendere to or been found guilty of a felony or a crime including but not limited to
crimes involving dishonesty, breach of trust, or a violation of any federal law or are you now under indictment?
Yes or
No
3. Have you ever had a complaint filed against you with an insurance department, NASD or other regulatory agency or do you
anticipate one being filed or have you ever been terminated by any company for cause?
Yes or
No
4. Are you at the present time involved in any litigation or are there any unsatisfied judgments or liens (including state or
federal tax liens) against you?
Yes or
No
5. Do you owe an insurance company or other person for any premiums collected or money advanced?
Yes or
No
6. Has any c