Mutual of Omaha General Agent Agreement (The Life Insurance Brokerage Pro)
Full Name:
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Date of Birth:
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Home Address ( must be a physical street address):
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Home Phone:
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Cell Phone:
Home Fax:
Email:
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Business Name:
Personal Business Address:
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NOTE: All correspondence (including compensation statements), will be mailed to the personal business address indicated. Only one business address is supported per individual. If no business address is indicated, mail will be directed to home address.
Address for overnight packages (cannot be a P.O. Box):
Business Phone:
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Business Fax:
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Business E-mail:
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Please identify your Master General Agency (if applicable):
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ERRORS AND OMISSION INSURANCE INFO
In accordance with the requirements of Mutual of Omaha and its affiliates, I agree to maintain professional liability insurance (referred to as Errors & Omissions coverage) covering the sales and service of Mutual of Omaha and its affiliates insurance products.
I will promptly notify Mutual of Omaha and its affiliates of any cancellations or major modifications to my coverage.
***E&O is not required to sell medicare supplement products.***
The Carrier this coverage is with:
Coverage in the amount of:
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BACKGROUND EXPERIENCE
Note: Please read each question carefully. Failure to answer "Yes" below, when appropriate, may result in the denial of your request to be contracted.
1) Have you ever been fined, suspended, placed on probation, paid administrative costs, entered into a consent order, been issued a restricted license or otherwise been disciplined or reprimanded, or are you currently under investigation by any insurance department, the NASD, SEC, or any other regulatory authority?
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Yes
No
2) Have you ever been convicted or plead guilty or nolo contendere (no contest), served any probation, paid any fines or court costs, had charges dismissed through any type of first offender or deferred adjudication or suspended sentence procedure, or are any charges currently pending against you for any offense other than a minor traffic violation?
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Yes
No
PROVIDE A WRITTEN EXPLANATION AND APPLICABLE SUPPORTING DOCUMENTATION (i.e., court documents, insurance department documents, etc.) FOR ANY QUESTION TO WHICH YOU RESPONDED "YES".
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GENERAL AGENT AGREEMENTS
CERTIFICATION
Under penalties of perjury, I certify that:
1. The number provided is my correct taxpayer identification number, and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien.)
Certification Instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
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I agree
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FAIR CREDIT REPORTING ACT DISCLOSURE
Mutual of Omaha Insurance Company and its affiliates with which you intend to contract (together, “Mutual of Omaha”) will obtain consumer reports for the purpose of serving as a factor in establishing your eligibility for contracting as an insurance producer.
“Consumer report” means a written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics or mode of living which will be used by Mutual of Omaha, in whole or in part for the purpose of serving as a factor in establishing your eligibility to be contracted as an insurance producer.
This means a credit report, criminal report and report of insurance department regulatory actions will be obtained and reviewed as part of a background investigation in order to determine your eligibility to be appointed.
By signing below, I acknowledge the “Fair Credit Reporting Act Disclosure to Consumers” has been provided to me.
CANDIDATE’S STATEMENT- READ CAREFULLY
Mutual of Omaha is hereby authorized to make any investigation of my criminal record history, insurance department history and credit history through any consumer reporting agency or through inquiries with my past or present employers, neighbors, friends or others with whom I am acquainted. I understand that this inquiry will include information as to my general reputation, personal characteristics and mode of living.
AUTHORIZATION
I authorize any consumer reporting agency, insurance department, law enforcement agency, the National Association of Securities Dealers, the Securities and Exchange Commission or any other person or organization having any records, data or information concerning my credit history, public record information, insurance license, regulatory action history or criminal record history to furnish such records, data and information to Mutual of Omaha.
I understand that if contracted, this authorization will remain valid as long as I am contracted with Mutual of Omaha.
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I agree
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SELECTION MODE OF ADVANCE
Mode of Advance
Please select one mode of advance from the choices below and acknowledge your choice by initialing under your selection. All choices are for advance of commission upon the issuance of an eligible Product.
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Six-Month (PN6)
Nine-Month (PN7)
Twelve-Month (PN8)
No Advance
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States in which to be appointed:
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TERMS AND CONDITIONS
You must agree to Mutual of Omaha and its Affiliates General Agent Agreement before proceeding. Please click on the Terms and Conditions link before agreeing below.
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I agree
ELECTRONIC SIGNATURE AGREEMENT
By checking below, I certify that all information contained in this document is accurate and can be considered legally binding.
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I agree
General Agent Name:
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General Agent Title:
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Signature Date:
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