TruAssure Appointment

Agent Information

First Name

Middle Initial

Last Name

SSN

NPN

Title

Are you working with a GA? If so, please enter their information below:

Name

Phone #

Please only enter a single email address.

Agency Information

Agency Name

TIN

Address

City

State

ZIP Code

County

Phone

Fax

Please only enter a single email address.

Appointment Details

Request Appointment as

Agent

Agency

Appointment Type

Accident & Health

Dental

Assignment of Commission

Commissions are to be paid/assigned to

Agent

Agency

Bank Information (Direct Deposit)

If Broker is interested in payment of commission via ACH, please also complete the ACH information. TruAssure will send the Broker statement to the e-mail address above.

Bank Name

Routing Number

Account Number

Account Name

Broker Number

Additional Information

Resident License State:

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

State:

License #:

State:

License #:

State:

License #:

Endorsement

1. Have you been convicted of a felony?

Yes

Please explain:

2. Have you committed a violation with any State insurance law, or violated or may be currently violating such law?

Yes

Please explain: