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Proposal Number
Agent / Consultant Information
Are there more than one writing agents on this account?
*
Yes
No
All writing agents receiving commission on products must be appointed in the group’s domiciled state.
Are there commission splits amongst the writing agents?
Yes
No
Any splits supplied will be the splits used for ALL bundled products sold.
<div class="repeater-field-header wpforms-repeater-field-large"> <div class="repeater-field-header-title">Agent # <span class="repeater-field-header-count">1</span></div> <div class="repeater-field-header-acctions"> <ul> <li><i class="repeater-icon icon-down-open repeater-field-header-acctions-toogle" aria-hidden="true"></i></li> <li><i class="repeater-icon icon-cancel-1 repeater-field-header-acctions-remove" aria-hidden="true"></i></li> </ul> </div> </div>
Name
National Producer
Street Address
State
Phone Number
Commission Split %
Signature
Clear Signature
SS# or EIN#
Agency Name
City
Zip
Email
Date
Submit