New Agent Form

Agent Data Form

Personal Information
First Name:
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MI:
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Last Name:
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Residential Address:
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City:
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State:
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Zip:
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Years At Address:
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Date Of Birth:
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Place of Birth:
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Sex:
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E-Mail:
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Home Phone:
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Cell Phone:
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Agency Information
Agency Name:
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Insurance Licensed:
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Mailing Address:
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City:
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State:
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Zip:
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Type:
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Date of Incorporation:
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Personal Reference 1
First Name:
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Last Name:
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City:
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State:
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Phone:
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Personal Reference 2
First Name:
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Last Name:
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City:
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State:
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Phone:
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Background Info
GA Name:
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State Licenses Held:
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Lines of Authority
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Medicare Certified?
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Are there any potential complications such as bankruptcies, criminal history, debt balances, liens, pending lawsuits or other issues that may hinder contracting?
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If yes, please write a brief Letter of Explanation, date, sign accordingly and send in with your contracts.
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Do you currently have Errors and Ommissions Insurance?
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Have you ever had a claim against it?
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Name of Carrier:
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Coverage Amount:
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Employment History
Name:
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Address:
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City:
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State:
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Zip:
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Phone:
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Position:
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Employment Dates:
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Reason For Leaving:
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Name:
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Address:
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City:
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State:
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Zip:
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Phone:
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Position:
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Employment Dates:
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Reason For Leaving:
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Name:
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Address:
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City:
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State:
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Zip:
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Phone:
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Position:
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Employment Dates:
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Reason For Leaving:
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Personal Production
Medicare Supplement:
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Medicare Advantage:
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Life Insurance:
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Health Insurance:
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Annuities:
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Misc:
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Medicare Supplement:
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Medicare Advantage:
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Part D:
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Life Final Expense
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Miscellaneous Products:
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Recruiting Manager:
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(*)
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TLC Offers many more Life & Annuity carriers that you can choose from. Please contact a TLC Sales Representative for those options.

Main Office 

1.800.719.3751

Contact Us

1-800-719-3751
(330) 637-2618
8700 East Market Street, Suite 8
Warren, OH 44484

Our Location