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Are You Contracting As An:

Have your commissions paid to Entity (LLC, Corp, etc) or paid directly to You, Agent? **Assigning Commissions needs to be discussed with the WISE OWL Contracting Team**

First Name

Last Name

Personal/Entity Information

Personal NPN

Social Security #

Driver's LIcense #

Birth Date

Birth City and State

Gender

Male
Female

Cell Phone Number

Home Phone Number

Phone Number (Business)

Fax #

Email Address

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Do you have a Mailing Address different then your Home Address?

Yes
No

Previous Address for Last 10 Years

What state do you plan on writing most of your business?

Background Information

1) Do you have any indebtedness to an Insurance Company?

2) Have you ever been convicted of a felony, or a misdemeanor, other than a traffic offense?

3) Have you ever had your Driver's License revoked?

4) Are you in process, or have you ever filed for Bankruptcy, declared bankrupt or insolvent, or had salary garnished?

5) Are you now or have you ever been employed by, or associated with to any degree, directly, or indirectly, a bank, savings and loan or other financial institution?

6) Are you now subject of any complaint, investigation, or proceeding which could result in a yes answer to any of thepreceding questions?

7) Have you ever been refused a bond or Errors and Omissions Insurance?

8) Have you ever had your insurance license suspended or revoked?

9) Have you been fined or had disciplinary action taken against you with any Department of Insurance?

10) Are you, at present, or within the past five years, been involved in any civil litigation, judgments, liens or foreclosures?

11) Have you ever been denied an appointment with any insurance company?

12) Have you ever been terminated for cause by any insurance carrier?

Additional Information

List a Beneficiary

Beneficiary Relationship

Have you taken an Anti-Money Laundering Course within the past 2 years?

Are you Registered Rep with FINRA?

Required Documents

1) E & O Certificate

Click or drag a file to this area to upload.

IF you do not have E & O Insurance you may purchase it through 360 Coverage Pros

2) Banking Information

Voided Check

PLEASE NOTE: Name On Check Needs to Match Who Will Be Appointed

If selected Entity needs to have the ENTITY name; if Agent needs to have your name.

ALSO: MUST BE A CHECK NOT A DIRECT DEPOSIT FORM

Financial Institution

Bank Routing #

Account Number

Voided Check

Click or drag a file to this area to upload.

3) Resident Insurance License

IF you need a copy of your License click: NIPR: License Printing by State

Personal Resident License

Click or drag a file to this area to upload.

Non Resident States

Upload ALL Non-Res Licenses

Click or drag files to this area to upload. You can upload up to 20 files.

Carrier Appointments

If uncertain which carriers to pick please reach out to us.

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Opt In

I agree to receive messaging from Wise Owl Insurance Group at the phone number provided above. I understand data rates may apply and may reply STOP to opt out.

STATEMENT OF UNDERSTANDING

(PLEASE READ CAREFULLY)

I hereby authorize WISE OWL and its affiliates (“The Authorized Parties”), to to affix or append a copy of my signature, as set forth below, to any and all required signature fields on forms and agreements of any insurance carrier (a “Carrier”) designated by me through electronic or paper contract submission, software and/or through any other means, including without limitation, by e-mail 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 authorized to sell Carrier insurance products. I hereby release, indemnify 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 clicking Submit below, I certify that the information 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 against 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.

By clicking Submit, I acknowledge that all information is true and correct to the best of my knowledge.

Appointment/Contracting Kit

Personal/Entity Information

Background Information

Additional Information

Required Documents

2) Banking Information

3) Resident Insurance License

Carrier Appointments

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Other Allignment Questions

STATEMENT OF UNDERSTANDING