Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
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.
Agent #1 Name
*
Agent #1 National Producer
*
Agent #1 Street Address
*
Agent #1 State
*
Agent #1 Phone Number
*
Agent #1 Comission Split %
Agent #1 Signature
Clear Signature
Agent #1 SS# OR EIN#
*
Agent #1 Agency Name
*
Agent #1 City
*
Agent #1 ZIP
*
Agent #1 Email Address
*
Agent #1 Date
*
Agent #2
Agent #2 Name
Agent #2 National Producer
Agent #2 Street Address
Agent #2 State
Agent #2 Phone Number
Agent #2 Comission Split %
Agent #2 Signature
Clear Signature
Agent #2 SS# OR EIN#
Agent #2 Agency Name
Agent #2 City
Agent #2 ZIP
Agent #2 Email Address
Agent #2 Date
Add another writing agent on this account?
Yes
No
Agent #3
Agent #3 Name
Agent #3 National Producer
Agent #3 Street Address
Agent #3 State
Agent #3 Phone Number
Agent #3 Comission Split %
Agent #3 Signature
Clear Signature
Agent #3 SS# OR EIN#
Agent #3 Agency Name
Agent #3 City
Agent #3 ZIP
Agent #3 Email Address
Agent #3 Date
Submit