Request to Add Contracts or Update Information

Your Information

Has your name or email address changed? *

What has changed? *

Name

Resident State License *

PDF Upload your resident state license reflecting your new name.

What was your former name? *

This information will be used to make sure all instances of your former name are updated.

Enter your new name when completing below.

New Email Address *

First Name *

Last Name *

Enter your OLD email address when completing below.

Email *

Social Security Number *

Date Of Birth *

Do you need to update your Phone Number, Address, or Driver License Information? *

What do you need to update? *

Phone Number

Address

Driver License

New Phone Number *

New Address (No PO Boxes) *

Address Line 1
Address Line 2
City
State
Zip Code

New Driver License Number *

New Driver License State *

New Driver License Expiration *

Licenses

I need to update my resident license information or start being paid as a business. *

I want to:

Update my resident license

Get paid as a business

Resident State License Number *

State License *

PDF Upload copy of state insurance license. A screenshot of your state website showing your active license is acceptable if saved and uploaded as a PDF.

Does the business hold a current state license in the company's name? *

Yes

In order to contract and receive commissions as a business, the business must have a license, National Producer Number, and an EIN.

Please obtain an insurance license for the business or proceed with contracting as an individual.

Agency's Resident License *

PDF

Business EIN *

Business Name *

Business Phone *

Business Principal Agent Name *

Business Email *

Corporate Address (No PO Boxes) *

Address Line 1
Address Line 2
City
State
Zip Code

Legal Questions

Do you need to update the answers to the legal questions?

Yes

Direct Deposit Information

I need to update my Direct Deposit information on file. *

The information entered today will only be used for future contract requests. *

Read

Unread

Agents are responsible for updating their banking information with already contracted carriers. The information added today will be kept on file and used for all future requests.

The information entered today will only be used for future contract requests. must be Read.

Enter the account information where you wish your commissions to be deposited.

This information is never used for billing purposes; only for bonuses, commissions, and overrides.

Account Owner *

First Name
Last Name

Routing Number *

Account Number *

Financial Institution Name *

Account Type *

Checking

Savings

Voided Check or Direct Deposit Form *

PDF Checks must be printed with your information, blank starter checks not accepted. Typed bank direct deposit or EFT forms are also accepted. Most banks have direct deposit forms available for download through online banking.

Have you been notified by the IRS that you're subject to backup withholding? *

By signing below I hereby authorize the Company to initiate credit entries and, if necessary, adjustments for credit entries in error to the checking and/or savings account indicated on this form. This authority is to remain in full effect until the Company has received written notification from me of its termination. I understand that this authorization is subject to the terms of any agent or representative contract, commission agreement, or loan agreement that I may have now, or in the future with the Company.

Direct Deposit Signature *

Clear

Date Signed *

Request to Add Contracts or Update Information

Your Information

Licenses

Legal Questions

Direct Deposit Information

Enter the account information where you wish your commissions to be deposited.

This information is never used for billing purposes; only for bonuses, commissions, and overrides.

Carrier Selection

Purchase your E&O here:
https://www.napa-benefits.org/

Once purchased, please go back to the previous question, answer "Yes" on the "Do you have current E&O?" And upload it.

Disclaimer:
By selecting this option, you acknowledge that the carrier may contact you directly to obtain proof of an active Errors & Omissions (E&O) policy. Failure to provide a valid and current E&O certificate may result in delays or denial of your request.

Nassau RE Contracting Instructions

National Life Group Questionnaire

It is my responsibility to contact the carriers I'm already contracted with and update my information directly with them. The changes I request today will only be applied to future carrier contract requests.

Authorization to Submit Contracts and Disclosures

By signing and submiting this electronic request I understand and agree to the following:

Disclaimer:
By selecting this option, you acknowledge that the carrier may contact you directly to obtain proof of an active Errors & Omissions (E&O) policy. Failure to provide a valid and current E&O certificate may result in delays or denial of your request.

Request to Add Contracts or Update Information

Your Information

Licenses

Legal Questions

Direct Deposit Information

Enter the account information where you wish your commissions to be deposited.

This information is never used for billing purposes; only for bonuses, commissions, and overrides.

Carrier Selection

Purchase your E&O here:https://www.napa-benefits.org/

Once purchased, please go back to the previous question, answer "Yes" on the "Do you have current E&O?" And upload it.

Disclaimer:By selecting this option, you acknowledge that the carrier may contact you directly to obtain proof of an active Errors & Omissions (E&O) policy. Failure to provide a valid and current E&O certificate may result in delays or denial of your request.

Nassau RE Contracting Instructions

National Life Group Questionnaire

It is my responsibility to contact the carriers I'm already contracted with and update my information directly with them. The changes I request today will only be applied to future carrier contract requests.

Authorization to Submit Contracts and Disclosures

By signing and submiting this electronic request I understand and agree to the following:

Disclaimer:By selecting this option, you acknowledge that the carrier may contact you directly to obtain proof of an active Errors & Omissions (E&O) policy. Failure to provide a valid and current E&O certificate may result in delays or denial of your request.

Purchase your E&O here:
https://www.napa-benefits.org/

Disclaimer:
By selecting this option, you acknowledge that the carrier may contact you directly to obtain proof of an active Errors & Omissions (E&O) policy. Failure to provide a valid and current E&O certificate may result in delays or denial of your request.

Disclaimer:
By selecting this option, you acknowledge that the carrier may contact you directly to obtain proof of an active Errors & Omissions (E&O) policy. Failure to provide a valid and current E&O certificate may result in delays or denial of your request.