Contact Details

Full Name *

Phone *

Email *

Entity #

Office Number

Role *

Franchisee

Staff Member

Business Owner

Enter Your Franchisee's Information

Zee's Name

Zee's Phone Number

Zee's Email Address

Tell Us About Your Insurance License Status

License Status *

I am Licensed

I am not licensed, but I am enrolled in a course

I am not licensed, and not yet enrolled to a course

Course Information

Type of Course *

Course Provider *

Insurance Training Academy

Date Enrolled *

Test Date

Registered for Test (Y/N) *

Yes

Insurance Agent Profile

Address *

City *

State *

Postal code *

County

Date of birth *

Social Security Number *

Driver License # *

Driver License Exp. Date *

Lines of Business *

Business Information

Enter your business information if applicable, othewise, move to the next page.

Business Address

Business Phone Number

EIN

Banking Information

Commission Bank Name

Commissions Account Number

Commissions Account Routing Number

Bank Account Type

Checkings

Savings

Sweeps Bank Account Number if Different than Commissions

Bank Account Holder Name

I hereby authorize Freedom Insurance and its affiliates, to electronically make deposits and to initiate debit entries in the event of errors to the account named on this form. I hereby authorize the Financial Institution above to accept and post these transactions to my account.

Commissions Account Access Authorization *

Clear

Contracting Authorization

I, hereby authorize SuranceBay, LLC and its general agency customers (the "Authorized Parties") to affix or append a copy of my signature, as set forth below, to any and all required signature fiels on forms and agreements of any insurance carrier ("a carrier") designated by my through the SureLC software or through any other means, including withou limitation, by email or orally. The Authorized Parties shall be permitted to complete and submit all such forms and agreements on my behalf for the purpose of becoming authized to sell Carrier insurance products. I hereby release, idenminfy and hold harmless the Authorized Parties against any and all claims, demands, losses, damages, and causes of action, including expenses, costs and reasonable attorneys' fees which they may sustain or incur as a result of carrying out the authority granted hereunder.

By my signature below, I certify that the infomation I have submitted to the Authorized Parties is correct to the best of my knowledge and acknowledge that I have read and reviewed the forms and agreements which the Authorized Parties have been authorized to affix my signature. I agree to indemnify and hold any third party harmless from and agains any and all claims, demands, losses, damages, and causes of action, including expenses costs and reasonable attorneys' fees which such third party may incur as a result of its reliance on any form or agreement bearing my signature pursuant to this authorization.

Contracting Signature Authorization *

Clear

Upload Your Files

E&O Coverage

Upload your Errors and Omissions for P&C DAP Development LLC must be added to the policy as an additional insured

General Liability Coverage

Upload here

Commissions Voided Check

Upload a copy or a picture of a voided check

Sweeps Account Voided Check

Upload Sweeps Account Voided Check if Different than Commissions

AML Certificate

Upload your Anti-Money Laundering Training Certificate (for life contracts only)