Agent Appointment, Personal Profile Questionnaire, and Online Insurance Product request form.
What Insurance Products do you want on your website?
  Chesapeake Life Short-Term Medical:  Click Here for quoter preview
  American Life of NY Instant Term Life:  Click here for quoter preview
  BeniCard Discount Medical & Dental: Click here for quoter preview
Lloyds Travel Medical Insurance Click here for quoter preview
  Globe Whole Life Plan:  Click here for quoter preview
 
Agent Information
  First Name: 
  Middle Initial: 
  Last Name: 
  Social Security Number:  - -
  Gender: 
  Date of Birth:  ,
Home Address
  Home Address Line 1: 
  Home Address Line 2 (optional): 
  City: 
  State:   Zip Code:  -
Mailing Address
Agency Name
  Mailing Address Line 1: 
  Mailing Address Line 2 (optional): 
  City: 
  State:   Zip Code:  -
Current Website URL
  E-mail Address: 
  Residential Phone:  ( ) -
  Business Phone:  ( ) -
  Insurance License(s):
  Please check the state(s) in which you currently licensed to sell Life insurance and enter the appropriate state license number.
1.AK  2.AL  3.AR 
4.AZ  5.CA  6.CO 
7.CT  8.DC  9.DE 
10.FL  11.GA  12.HI 
13.IA  14.ID  15.IL 
16.IN  17.KS  18.KY 
19.LA  20.MA  21.MD 
22.ME  23.MI  24.MN 
25.MO  26.MS  27.MT 
28.NC  29.ND  30.NE 
31.NH  32.NJ  33.NM 
34.NV  35.NY  36.OH 
37.OK  38.OR  39.PA 
40.RI  41.SC  42.SD 
43.TN  44.TX  45.UT 
46.VA  47.VT  48.WA 
49.WI  50.WV  51.WY 
 
Compliance Questions
 
1. Have you or your agency EVER had an application for an insurance license denied, suspended, or revoked by any regulatory authority?  Yes No
2. Has an insurance carrier EVER terminated your insurance contract/appointment for reasons other than lack of production?   Yes No
3. Are there any outstanding judgments or tax liens (federal or state) against you or your agency?  Yes No
4. Have you or your agency EVER declared bankruptcy?  Yes No
5. Have you or your agency EVER been charged or convicted of a felony or misdemeanor involving theft, embezzlement, conversion, or any similar violation of the law?  Yes No
6. Have you or your agency EVER been known for or conducted business under a different name than stated on page one (excluding a name change due to marriage and/or divorce  Yes No
 
 

If you answered Yes to any of the above Compliance questions, please type an explanation in the textbox below.

By Typing my Full Name in this box I Agree to let SAS, Inc Submit my Licensing to each respective insurance carrier: