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: ● ● ● ● ● ● ● ● ● ● ● 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
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