Magnum ACE Appointment

Applicant Information

First Name

Middle Initial

Last Name

Nickname

Home Address

City

State

Zip

County

Social Security Number

Date of Birth

Gender

Male

Female

Cell Phone

Email Address

Please only enter a single email address.

Title

Working with GA?

Please enter the General Agency Name.

National Producer Number

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

Agency Information

Business Name

Business Phone

Business Fax

Business Email

Please only enter a single email address.

Business Tax Class

Business Address

Business City

Business State

Business Zip

Business Tax ID

Preferred Mailing Address

Send Correspondence to:

Business Address

Home Address

Assignment of Commission

Are you assigning your commission to an agency?

Yes

Assignee Information

Agency Name

Tax ID#

Tax Class

Address

City

State

Zip

Bank Information (Direct Deposit)

NOTE: Both live checks and direct deposit amounts must accrue to a total of $25, before commissions are issued. Monthly commission statements will be mailed to agents along with live checks; commission statements are not issued electronically. Brokers who elect EFT/Direct Deposit, will be able to access commission statements via the agent portal.

Financial Institution

Street Address

City

State

Zip

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

Attach E&O

NOTE: Licensing and Errors & Omissions Insurance is required to complete your application. If you are unable to upload a copy of your licensing and the summary page of your E&O there are a couple options: This can either be emailed to agentsupport@DirectBenefits.com or by fax at (651) 649-3502.

2. Please enter your Broker ID

3. Have you ever been convicted of, or currently charged with, any felony involving dishonesty or breach of trust?

Yes

Please explain this:

4. Have you ever been convicted of, or currently charged with, commiting a crime involving moral turpitude since becoming licensed?

Yes

Please explain this:

5. With the exception of credit life and disability insurance agents, are you employed by or associated with any degree, directly or indirectly, a financial institution as defined in section 626.988, F.S.?

Yes

Please explain this:

6. Have you ever been convicted of any crime under the Violent Crime Control and Law Enforcement Act of 1994 (18 United States Code, §§1033 and 1034)?

Yes

Please explain this:

7. Do you have an outstanding debt with any insurance company?

Yes

Please explain this:

8. Have you ever been bankrupt or insolvent, either personally or professionally?

Yes

Please explain this:

9. Has an insurance company ever canceled a contract with you for any reason other than lack of production?

Yes

Please explain this:

10. Have you ever had a complaint filed against you by a state or provincial insurance department?

Yes

Please explain this:

11. Have you ever had an insurance license denied or revoked by a state or province?

Yes

Please explain this:

12. Have you ever been refused a surety or fidelity bond?

Yes

Please explain this:

Additional Licensees

Click the button to add an additional licensee.

Licensee Information

Licensee Information

Licensee Information