New Agent Application - Phillips Stafford Insurance Group

Name*

First Last

Are you a producer or independent agent?*

Are you a Phillips Stafford Producer or an independent agency partner?

Producer
Independent Agent

Home Address*

Enter your current resident address

Street Address Address Line 2 City State ZIP Code

Business Address*

Enter the business address or PO Box you will use as an agent. If you will be a Phillips Stafford Producer enter the address of the branch office you will work out of primarily

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone*

Will you be using our phone system?*

Will you be using our phone system for $25/mo?

Yes
No

Business Phone*

Fax*

Date of Birth*

Social Security Number*

NPN*

National Producer Number

States You Are Licensed In*

How many years have you been a licensed Agent/Broker/Solicitor?*

Have you ever had a license surrendered, cancelled, suspended or revoked?*

Yes
No

Please Explain*

Have you ever had a complaint filed against you with and insurance department?*

Yes
No

Please Explain*

Have you ever been convicted of a felony?*

Yes
No

Please Explain*

Have you ever been convicted of a misdemeanor?*

Yes
No

Please Explain*

Are you at present involved in any litigation connected with the business of insurance?*

Yes
No

Please Explain*

Are you the subject of a child support related subpoena or warrant, or do you have a child support obligation past due?*

Yes
No

Please Explain*

Do you have unpaid tax liens, collection items or outstanding civil judgments?*

Yes
No

Please Explain*

Have you filed for, or been discharged from, any bankruptcy during the past five (5) years?*

Yes
No

Please Explain*

Have you ever been the subject of a repossession or foreclosure?*

Yes
No

Please Explain*

Have you ever failed to timely remit premiums to an insurance carrier causing policy cancellations and/or demand for payment from the carrier?*

Yes
No

Please Explain*

Have you ever had a contract or any other business relationship terminated for cause by an insurance carrier?*

Yes
No

Please Explain*

Are you now the subject of any complaint, investigation, or proceeding that could result to a YES to any of the previous questions?*

Yes
No

Please Explain*

Have you ever been a principal, owner, officer, or partner of an insurance agency or corporation that would be able to answer yes to any of the above questions?*

Yes
No

Please Explain*

Include the name of the agency or corporation and your relationship to that entity.

Files

Please upload the following:

1. Insurance license(s) for all state(s) you are licensed in.
2. Completed and signed W-9 form download

Drop files here or

Accepted file types: jpg, pdf, gif, png, Max. file size: 2 MB.

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