New Agent Form | TLC Insurance Group & Wealth

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This field is for validation purposes and should be left unchanged.

Name(Required)

First Name Middle Initial Last Name

Sex

Male

Female

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email(Required)

Phone(Required)

Insurance Licensed?

Yes

National Producer Number

Corporate Information If Contracting As An Agency

Agency Name

Agency Tax ID #

Agency Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Tax Classification(Required)

Individual

Corporate

LLC

Is your Agency licensed to sell insurance?

Yes

Necessary Documents Needed

TLC will need copies of the following for the contracting process: 1. Current copy of Insurance License(s) / Agency License(s) per state 2. Current copy of your E&O certificate 3. Voided check for direct deposits 4. Explanation / Supporting docs for any potential contracting issues 5. Any Releases, if needed, that have been secured Please include all necessary documents when you send back the Agent Data Form.

File

Max. file size: 300 MB.

Please provide a brief description of the files being uploaded

How did you hear about TLC Insurance Group(Required)

Referred by(Required)

Agent Manager Name(Required)

A TLC Representative will be in contact with you soon to discuss your next steps with TLC Insurance Group and Wealth.

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