Common Contracts
1 similar Individual Broker Agreement contracts
Individual Broker Agreement IAG COM Corporate Agency Agreement CAG COM Provisional Broker Agreement IAG PRVIndividual Broker Agreement • April 3rd, 2017 • Minnesota
AGENT FULL NAME(Last, First, Middle) DATE OF BIRTH/ / SOCIAL SECURITY NUMBER - - # MALE # FEMALE HEALTH INSURANCE LICENSE NUMBER MN WI ND SD Please attach copy of applicable license(s) (REQUIRED) NPN: AGENCY NAME FEDERAL TAX I.D. NUMBER AGENCY ADDRESS CITY/STATE /ZIP CODE AGENCY TELEPHONE FAX NUMBER COUNTY AGENT HOME ADDRESS CITY/STATE /ZIP CODE HOME TELEPHONE FAX NUMBER E-MAIL ADDRESS (Unique & REQUIRED) Send mail to (check one only): □.Agency address □.Home address □ Other - Please provide to Medica 1. Have you ever been convicted of a felony under state or federal law, or a crime involving dishonesty or breach of trust? □.Yes □.No2. Has any insurance disciplinary action ever been taken against you? □.Yes □.NoIf yes to either question, please provide dates, explain, and attach documentation: Errors & Omissions Insurance Carrier(REQUIRED) Level (amount) Exp. date Please attach copy of declaration page Policy Number Held by: # Self # Agency Assign commissions to: #. Agent #
