Associates of Clifton Park
(Regular)
P.O. Box 1259
Clifton Park, NY 12065
1-800-836-3914
[email protected]
(Overnight)
313 Ushers Rd
Ballston Lake, NY 12019
Fax # 518-877-7651
www.longtcare.com
Fax Cover Sheet
To: Licensing
Fax: (518) 877-7651
Date: ____________
Pages including cover: ____________
From (please print name): _________________________________
Manager Name: _________________________________________
Branch Number: __________________
State(s) (to be appointed in): ____ ____ ____ ____ ____ ____ ____
~Please attach any appropriate state required Continuing Education Credits~
~ (CA, CO, CT, IL, IN, MD, NY, WA) ~
~If you are a resident of MASSACHUSETTS, please attach the required State form~
**PLEASE INCLUDE A COPY OF YOUR LIFE & HEALTH/LTC LICENSE**
Updated 02/26/07 TT
APPOINTMENT APPLICATION
Marquette National Life Insurance Company
1001 Heathrow Park Lane, Lake Mary, Florida 32746
____________________________________________________________
Applicant Name
______________________________________________________
Home Address
______________________________________________________
Prior Address
______________________________________________________
Date of Birth
This contract is to be executed as:
π Individual / Sole Proprietor
________________________________________________
Social Security / Tax ID#
______________________________ ________________ __________________
City
State
Zip
______________________________ ________________ __________________
City
State
Zip
____________________________________________________________________
Home Phone
π Partnership
π Corporation
Appointment to be in the name of: ____________________________________________________________________________________
Appointment is requested in the following states: ________________________________________________________________________
______________________________________________________
Business Address
______________________________________________________
UPS Address
______________________________________________________
Bus. Phone
______________________________________________________
Email Address
______________________________ ________________ __________________
City
State
Zip
______________________________ ________________ __________________
City
State
Zip
____________________________________________________________________
Fax Number
INSURANCE EXPERIENCE
Companies
you currently represent __________
Year
Volume
Companies
you currently represent __________
Year
Volume
__________________________________
______________
__________________________________
__________________
__________________________________ __________ ______________ __________________________________ __________ __________________
__________________________________ __________ ______________ __________________________________ __________ __________________
__________________________________ __________ ______________ __________________________________ __________ __________________
CERTIFICATION / BACKGROUND INFORMATION
1. Have you ever had your insurance license suspended or revoked? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . π Yes
2. Is your insurance license currently restricted or under investigation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . π Yes
3. Have you ever been refused a surety bond or had a claim paid for you? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . π Yes
4. Have you ever filed for bankruptcy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . π Yes
5. Have you ever been convicted of a felony or misdemeanor, excluding traffic violations? . . . . . . . . . . . . . . . . . . . . . . π Yes
6. Are you at present involved in any litigation or administrative proceeding related to the
insurance business or are there unsatisfied judgments against you? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . π Yes
7. Have you ever been listed as debarred, excluded or otherwise ineligible for participation
in federal health care programs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . π Yes
(Please explain any “yes” answers on a separate sheet, inclusive of dates and attach such to this Application.)
π
π
π
π
π
No
No
No
No
No
π No
π No
In making this application to represent Marquette National Life Insurance Company, it is understood that investigative reports may be
made whereby information is obtained through credit reports, insurance department records and/or criminal records. You have the right
to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning
the nature and scope of the investigation. We will use this information to assist in the appointment determination. If we decide not to
approve you as a result of the information disclosed or as a result of our investigation, we will inform you in writing in accordance with
the Fair Credit Reporting Act (FCRA).
I declare that this application presents, to the best of my knowledge, an accurate statement of facts, and I give my authorization to the
Company to conduct an investigation of these facts as it may deem appropriate.
______________________________________________________
Applicant Signature
____________________________________________________________________
Date
TO BE COMPLETED BY MANAGING GENERAL AGENT
______________________________________________________
General Agent (print)
______________________________________________________
Agent Number
__________________________________________________________________
Signature
______________________
________________________________________
Date
Contract Level
______________________________________________________
Home Office Approved by
______________________
Date
MQ AGTAPP 05
Market Conduct and Advertising Compliance
I hereby acknowledge receipt and understanding of:
●
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●
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AGENT LICENSING PROCEDURES
RULES GOVERNING SALES PRACTICES
RULES GOVERNING USE OF ADVERTISEMENT OF LIFE, HEALTH AND ANNUITY
CONTRACTS
INTERCOMPANY REPLACEMENT RULE
HIPAA BUSINESS ASSOCIATE CONTRACT PRIVACY ADDENDUM
AGENT CODE OF PROFESSIONAL ETHICS
INSURANCE FRAUD
CLAIMS
PRIVACY
ANTI-MONEY LAUNDERING PROGRAM ACKNOWLEDGEMENT
USA PATRIOT ACT AND ANTI-MONEY LAUNDERING
I understand that if anything in the above referenced rules applies to me or my affiliations with the
Company, my sub-agents (if any) and I will: (1) follow these rules accordingly; (2) monitor any activity
applicable to these rules; and (3) report any infraction to my manager.
Agent Name: (Print)
Signature:
Date:
A copy of this signed acknowledgment becomes a part of the agent’s contract file.
The above acknowledgment form must be signed, dated and
returned with Licensing and Contracting paperwork
LMB - MC/ACK (7/06)
APPOINTMENT ONLY AGREEMENT
AN AGREEMENT BETWEEN Marquette National Insurance Company (the Company) and
Agent Name ___________________________________________________________
(Please Print)
The Company is requested to make application to the Department of Insurance of the applicable State(s) for the issuance of an
appointment authorizing Agent to solicit applications on behalf of the Company.
Agent hereby agrees that Company’s consent to the issuance of such appointment(s) is subject to, and Agent hereby agrees to be
bound by, each and all of the following conditions:
1.
That Agent shall be an agent assigned to, and under contract with Managing Sales Representative, indicated below; and
2.
That the Company has no obligation to Agent for commissions, expense allowances or any form of compensation whatsoever
in connection with the services performed and expenses incurred by Agent in the solicitation of applications for insurance
submitted to the Company. It is expressly understood that Agent is under direct contract with Managing Sales Representative,
who has agreed to compensate Agent for such services; and
3.
That Agent has no other contractual relationship with the Company and that Agent is not, and shall refrain from portraying Agent
as an employee, partner, or joint venturer of the Company; and
4.
That Agent shall comply with the rules, regulations, underwriting guides, rate guides and any other directives of the Company,
all federal regulations, the laws of the states in which Agent is licensed and appointed, and the regulations of the Departments of
Insurance relating to activities in the solicitation of insurance; and
5.
That Agent shall not alter, modify, waive or change any of the terms, rates or conditions of any Company material including;
advertisements, receipts, policies or contracts of the Company in any respect; and
6.
That Agent shall promptly remit to the Managing Sales Representative, or to the Company all monies received by Agent on behalf
of the Company for first year premiums, or any other items relative to the Company’s business whatsoever; and
7.
That Agent shall not obligate the Company or incur expense on Company’s behalf in any manner whatsoever; and
8.
Agent hereby agrees to indemnify and hold the Company, its employees, officers and directors harmless from and against any
and all liability, payment, loss, cost, expense (including reasonable attorneys’ fees and costs), or penalty incurred by Company, its
employees, officers or directors in connection with any claim, suit, or action asserted against such entity or person resulting from
the failure to fulfill any obligation of this Agreement by Agent, its agents or subcontractors; and
9.
During the term of this Agreement and for a period of two years after this Agreement is terminated for any reason, Agent will not
directly or indirectly on Agent's behalf or on behalf of any other, solicit, encourage or induce any Company or Company affiliate
policyholder to cancel, lapse, surrender, replace or otherwise terminate any policy issued by the Company or Company's affiliate;
and
10. That the Company may, without liability to Agent whatsoever, upon receipt of directive from Managing Sales Representative or
upon Company’s own initiative, cancel Agent’s appointment(s) with required notice; and
11. Company has the right to terminate this Agreement for cause due to Agent’s breach of any condition of this Agreement or due to
Agent’s revocation of Insurance License in any State or jurisdiction.
Agent is requesting appointment in the following states: ______________________________________________________________________.
___________________________________________________ ________________________
Signature of Agent
Date
___________________________________________
Marquette National Agent Number
This applicant is recommended for appointment as an agent assigned to my agency, subject to all of the terms of my Managing Sales
Representative’s contract with the Company and this Agreement.
___________________________________________________________
Signature of Managing Sales Representative
___________________________________________________________
Federal Tax ID #
___________________________________________________________
Managing Sales Representative-Please Print
___________________________________________________________
Marquette National Agent Number
The Company approves this Agreement and appointment subject to all of the provisions herein.
BY:
_____________________________________________
Authorized Home Office Signature
MQ LOA 05
_____________________
Date