HCC Appointment

Applicant Information

First Name

Middle Initial

Last Name

Home Address

City

State

Zip

Social Security Number

Date of Birth

Gender

Male

Female

Are you a US citizen?

Yes

Home Phone Number

Cell Phone Number

Home Fax Number

Email Address

Please only enter a single email address.

How did you hear about us?

Please add any additional details (ex: web page name, ad source, agent name, etc)

If you are working with a General Agent

Please enter the General Agency Name.

National Producer Number

Don't know your NPN? Click here to search.

Agency Information

Business Name

Legal Name of Business

Business Phone Number

Business Fax Number

Email Address

Please only enter a single email address.

Business Tax Class

Business Address

Business City

Business State

Business Zip

Assignment of Commission

Are you assigning your commission to an agency?

Yes

Assignee Information

Agency Name

TIN#

Tax Class

Address

City

State

Zip

Bank Information (Direct Deposit)

NOTE: Checks or direct deposit will need to accrue to a total of $5 before the commissions are issued. Monthly commission statements will be mailed to agents (not issued electronically.)

Name on account

Financial Institution

City

State

Account Type

Checking

Savings

Routing Number

Account Number

Additional Information

1. Provide the state(s) in which you wish to be appointed

Attach License File 1

Attach License File 2

Attach License File 3

NOTE: Please upload applicable license files for selected states above.

2. Do you carry Errors & Omissions insurance?

Yes

E&O Policy Number

3. Have you ever had an application for an insurance license declined by an insurance department?

Yes

Please explain this:

4. Have you ever had an insurance license suspended or revoked by an insurance department, or had a complaint issued against you by any insurance department?

Yes

Please explain this:

5. Is any charge by any state currently pending against you, the agency, or any member of the agency?

Yes

Please explain this:

6. Have you ever been charged with or convicted of a felony or of any crime involving moral turpitude?

Yes

Please explain this:

7. Are there any outstanding judgments or liens (including state or federal tax) against you?

Yes

Please explain this:

8. Has your appointment ever been terminated by an insurance company for reasons other than lack of production?

Yes

Please explain this:

9. Does any insurer, insured, or other person claim any indebtedness of you as a result of any insurance transaction or business?

Yes

Please explain this: