Registered Representative & Fixed Agent Contract Application
Agent Number ______________________
(Home Office Use Only)
Licensing Requirement: You must complete the online Agent Certification (Instructions and log-in information to be provided.) and
AML Training before you solicit any Fixed Annuity Business.
DATE OF BIRTH
SOCIAL SECURITY NUMBER
NATIONAL PRODUCER NUMBER
TYPE OF APPOINTMENT
o FIXED o VARIABLE o BOTH
o INDIVIDUAL o CORPORATION+
TAXPAYER ID NUMBER
RESIDENCE ADDRESS - STREET, CITY, STATE, COUNTY, ZIP
BUSINESS ADDRESS - STREET, CITY, STATE, COUNTY, ZIP
o RES. PHONE o BUS. PHONE o CELL PHONE o E-MAIL
PROFESSIONAL DESIGNATION o CLU o CHFC o LUTCF o CFP__________ o OTHER__________
SECURITIES LICENSES* o 6 o 7 o 24 o 26 o 63 o RIA STATES___________________
BROKER/DEALER ADDRESS* - STREET, CITY, STATE, COUNTY, ZIP
oYes oNo Have you ever been convicted, pled guilty or nolo contender, or do you have pending charges to a felony or misdemeanor? If yes, attach copy of court records.
oYes oNo Have you ever had any regulatory action taken against you, or had your insurance or securities license denied, suspended, terminated or revoked by an insurance
department, FINRA or any other regulatory agency?
oYes oNo Have you ever had a complaint filed or do you anticipate a complaint being filed against you by a consumer, an insurance department, FINRA or any other regulatory
oYes oNo Has your contract or appointment ever been terminated involuntarily by an insurer or FINRA member firm?
oYes oNo Has any claim ever been made against you, your surety company or errors and omissions insurer arising out of insurance and/or securities sales?
oYes oNo Are you currently involved or ever been involved in litigation?
oYes oNo Do you have past due financial obligatio