Agent Appointment Application
Monumental Life Insurance Company
Partner: Employer Benefit Underwriters, Inc.

All Areas Must be Completed. Please Print or Type.

Personal Information

Full Name
Residence Address
Prior Residence (if less than 5 years)
Residence Phone (          ) Social Security Number
Date of Birth _____/_____/_____ Male _____     Female _____
Marital Status Spouse's Name

Business Information

Business Name
Business Address
Mailing Address
Business Phone (          ) Business Fax (          )
Email Address Currently Member of NALU? ____ Yes  ____ No
Years in Business NASD Registered? ___ Yes  ___ No If Yes, NASD Series #
Licensed to Sell: ____ Life   ____ Health   ____ Annuity   ____ Variable Annuity
Resident State License # Type of License

** Please include copies of resident and non-resident licenses **
List any non-resident states in which you are currently licensed, and wish to be appointed

 
List Companies Currently Contracted with
Name of E & O Carrier E & O Policy #
Make Commissions Payable to: ___ Individual  ___ Corporation (include copy of corporation license, if applicable)
Corporation Name Tax ID #

Employment History
Include insurance companies you are contracted with, or have been contracting during the last 5 years.  If you have less than 5 years experience, please include employment history for the last 10 years.

From

To

Company

Address (City and State)

Phone Number

May We Contact

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If the answer is YES to any of the following questions, please give a complete explanation on a separate sheet of paper. Failure to provide sufficient detail in accurate form will result in delay or denial of your appointment.

 

YES

NO
Are you currently charged with or have you plead guilty or no contest to, or been convicted of, any crime (excluding minor traffic offenses)?

 

 

Are you now or have you ever been the subject of any lawsuit, claim, investigation or proceeding alleging breach of trust or fiduciary duty, forgery, fraud or any other act of dishonesty?

 

 

Have you ever had your agent’s license or registration suspended or revoked, or are you now, or have you ever been the subject of a professional license/registration or market conduct investigation, claim or proceeding?

 

 

Have you ever been involuntarily terminated or permitted to resign from employment or from an agent or representative appointment with any insurance or other financial services company other than for lack of production?

 

 

Has a bonding, surety or E&O provider denied an application or claim, made payment for you or terminated coverage?

 

 

Are you delinquent in any personal or business financial obligations, or does any insurance or financial services company hold a claim against you for commission debit balances?

 

 

Are there any outstanding judgments, liens or claims against you, including delinquent tax obligations or bankruptcy?  Bankruptcy Discharge Date ________________

 

 

Have you ever done business under another name?

 

 

At any time during the past 10 years have you, or any business in which you were an owner, partner, officer or director, been involved in any regulatory, civil or criminal matters not disclosed above?

 

 

Fair Credit Reporting Act Notice/Consumer Authorization
I hereby authorize and request any present or former employer, police department, financial institution, insurance company, department of insurance, or other persons having knowledge about me, to furnish bearer with any and all information in their possession regarding me in connection with an application for appointment as an insurance agent.  I agree that a photocopy of this authorization may be accepted with the same authority as the original, and I specifically waive any written notice from any present or former employer who provides information based upon this authorized request.  

I have been given a stand-alone consumer notification that a report may be requested and used for the purpose of evaluating me for appointment as an insurance agent.  

I acknowledge that I am familiar with the insurance and securities law (if applicable) and regulations of the jurisdictions to which I an applying for appointment.

I understand and agree that I am not authorized and am expressly forbidden to solicit business for the company until my license and appointment have been secured.

Under penalty or perjury, I certify that the Social Security Number shown or tax payer identification number shown on this form is my correct taxpayer identification number and I am not subject to backup withholding by the Internal Revenue Service.

The undersigned hereby acknowledges the receipt of the Code of Professional Conduct. The undersigned further acknowledges that he/she has reviewed the Code of Professional Conduct.  The undersigned is committed to conduct his or her insurance activities on behalf of Monumental Life Insurance Company, in conjunction with the statutory companies of AEGON, USA, Inc. with the highest standards of honesty and integrity.  The business practices of these companies shall be consistent with the Code of Professional Conduct and the Insurance Marketplace Standards Association.

I acknowledge that my job responsibilities now include a commitment to the Code of Professional Conduct as follows:  Responsible for conducting business on behalf of the Company in accordance with the Code of Professional Conduct which has been committed to by the Company and is consistent with the Insurance Marketplace Standards Association’s Principles and Code of Ethical Market Conduct.

In connection with the marketing of Monumental Life’s products and the servicing of Monumental Life’s customers, I will comply with all applicable laws and regulations requiring protection of privacy of nonpublic personal information about any applicant or potential applicant for insurance, or about a policyholder, insured, beneficiary or other consumer, and I will not disclose or use any such information provided to me by Monumental Life except as necessary to carry out the purposes for which it was provided.

_________________________
Date 

 

________________________________________________________
Signature

 

________________________________________________________
Printed Name


Consumer Notification

This is used to inform you that a consumer report or an investigative consumer report may be obtained from a consumer reporting agency for the purpose of evaluating you for appointment as an agent with our company.

This report may contain information bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living from public record sources.  You may also have a right to request additional disclosures regarding the nature and copy of the investigation.

A Summary of Your Rights Under the Fair Credit Reporting Act

The Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness and privacy of information in the files of every “consumer reporting agency” (CRA).  Most CRAs are credit bureaus that gather and sell information about you - such as where you work and live, if you pay your bills on time, and whether you’ve been sued, arrested, or filed for bankruptcy - to creditors, employers, and other businesses.  The FCRA gives you specific rights in dealing with CRAs, and requires them to provide you with a summary of these rights as listed below.  You can find the complete text of the FCRA, 15 U.S.C. 1681 et seq., at the Federal Trade Commission’s web site (http://www.ftc.gov).

You must be told if information in your file has been used against you. Anyone who uses information from a CRA to take action against you - such as denying an application for credit, insurance or employment - must give you the name and address and phone number of the CRA that provided the report.

You can find out what is in your file. A CRA must give you all the information in your file, and a list of everyone who has requested it recently.  However, you are not entitled to a “risk score” or a “credit score” that is based on information in your file.  There is no charge for the report if your application was denied because of information supplied by the CRA, and if you request the report within 60 days of receiving the denial notice.  You are also entitled to one free report a year if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud.  Otherwise, a CRA may charge you a fee of up to eight dollars.

You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must reinvestigate the items (usually within 30 days) unless your dispute is frivolous. The CRA must pass along to its source all relevant information you provided.  The CRA also must supply you with written results of the investigation and a copy of your report, if it has changed.  If an item is altered or deleted because you dispute it, the CRA cannot place it back in your file unless the source of the information verifies its accuracy and completeness, and the CRA provides you a written notice that includes the name, address, and phone number of the source.

Inaccurate information must be deleted. A CRA must remove inaccurate information from its files, usually within 30 days after you dispute its accuracy.  The largest credit bureaus must notify other national CRAs if items are altered or deleted.  However, the CRA is not required to remove data from your file that is accurate unless it is outdated or cannot be verified.

You can dispute inaccurate items with the source of the information.  If you tell anyone - such as a creditor who reports to a CRA - that you dispute an item, they may not then report the information to a CRA without including a notice of your dispute.  In addition, once you’ve notified the source of the error in writing, they may not continue to report it if it is in fact an error.

Outdated information may not be reported.  In most cases, a CRA may not report negative information that is more than seven years old; ten years for bankruptcies.

Access to your file is limited.  A CRA may provide information about you only to those who have a need recognized by the FCRA - usually to consider an application you have submitted to a creditor, insurer, employer, landlord, or other business.

Your consent is required for reports that are provided to employers or that contain medical information.  A CRA may not report to your employer, or prospective employer, about you without your written consent.  A CRA may not divulge medical information about you without your permission.

You can stop a CRA from including you on lists for unsolicited credit and insurance offers.  Creditors and insurers may use file information as the basis for sending your unsolicited offers of credit or insurance.  Such offers must include a toll-free number for you to call and tell the CRA if you want your name and address excluded from future lists for two years.  If you request and complete the CRA form provided for this purpose, you can have your name and address removed indefinitely.

You may seek damages from violators.  You may sue a CRA or other party in state or federal court for violations of the FCRA.  If you win, the defendant may have to pay damages and reimburse you for attorney’s fees.  If you lose and the court specifically finds you sued in bad faith, you or your attorney may have to pay the defendant’s fees.

You may have additional rights under state law.  You may wish to contact a state or local consumer protection agency or a state attorney general to learn those rights.

The FCRA gives several different federal agencies authority to enforce the FCRA.