Combined Insurance Appointment

Applicant Information

First Name

Middle Initial

Last Name

Social Security Number

Date of Birth

Working with GA?

Please enter the General Agency Name.

Agency Information

Name

Your Title

Address

City

State

Zip

Business Tax Class

Tax ID #

Phone Number

Email Address

Please only enter a single email address.

National Producer Number

Bank Information (Direct Deposit)

Name on account

Bank Name

Address

City

State

Zip

Account Type

Checking

Savings

Account Number

ABA/Routing Number

Additional Information

Select the states in which you would like to be appointed. Please provide your license numbers for each respective state and attach a copy of the license.

State:

License #:

Attach License

State:

License #:

Attach License

State:

License #:

Attach License

Please also attach a copy of the deck page of your E & O coverage.

Attach E&O

NOTE: A copy of your agent licensing (and agency if applicable) and E&O coverage is REQUIRED complete your application. If you are unable to upload copies of these, you may also email it to Carrissa@DirectBenefits.com or fax it to (651) 649-3502.

Questionaire

For the following questions, "you" refers to the individual or entity seeking to be appointed with Combined Insurance Company of America.

Has your license ever been revoked or suspended?

Yes

Please explain this:

Have you ever had a complaint filed against you with the Insurance Department or other regulatory body?

Yes

Please explain this:

Has your appointment with any other insurance company ever been terminated for cause?

Yes

Please explain this:

Have you ever been licensed under any other name?

Yes

Please explain this:

Have you ever filed bankruptcy or had judgments or liens filed against you?

Yes

Please explain this:

Are you currently delinquent on any of your obligations?

Yes

Please explain this:

Have you or any of your employees or principal ever been convicted of a felony?

Yes

Please explain this:

Have you ever failed to earn or repay commission advances?

Yes

Please explain this:

Have you ever been sued for alleged errors or omissions as an insurance agent or broker, or for any alleged breach of trust?

Yes

Please explain this: