New Agent Contracting

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Your Information

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(Hidden) Prevent Creating a User

Yes

Have you used SuranceBay/SureLC with another agency or IMO?(Required)

Yes

Since you've previously used SuranceBay, please CLICK HERE to add yourself as a New User to our SuranceBay. (All SuranceBay portals look the same, you MUST select New User.)

Did you add yourself to our SuranceBay?(Required)

Yes

Name(Required)

First Last

Social Security Number(Required)

*REQUIRED - Must be completed accurately or else request will be rejected.*

Email(Required)

Phone(Required)

Driver License(Required)

Driver License State(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Gender on Driver License(Required)

Male

Female

Decline to State

This is only used for contracting purposes and to assist with any background checks a carrier may run.

Address (No PO Boxes)(Required)

Street Address Address Line 2 City State ZIP Code

Beneficiary

Who will collect your commissions in the event of your death?

First Last

Beneficiary Social Security Number

Beneficiary DOB

MM slash DD slash YYYY

Employment & Address History

List 5 years employment history

Employer 1: Position(Required)

Employer 1: From(Required)

MM slash DD slash YYYY

Employer 1: To(Required)

MM slash DD slash YYYY

Employer 1: Company(Required)

Employer 1: Location(Required)

Employer 2: Position

Employer 2: From

MM slash DD slash YYYY

Employer 2: To

MM slash DD slash YYYY

Employer 2: Company

Employer 2: Location

Employer 3: Position

Employer 3: From

MM slash DD slash YYYY

Employer 3: To

MM slash DD slash YYYY

Employer 3: Company

Employer 3: Location

List 5 years address history

Address 1: From(Required)

MM slash DD slash YYYY

Address 1: To(Required)

MM slash DD slash YYYY

Address 1(Required)

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

Address 2: From

MM slash DD slash YYYY

Address 2: To

MM slash DD slash YYYY

Address 2

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

Address 3: From

MM slash DD slash YYYY

Address 3: To

MM slash DD slash YYYY

Address 3

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

License & Certifications

Doing Business As:(Required)

Individual

Business

Business Insurance License(Required)

Max. file size: 256 MB.

In order to contract as a business, your business is required to have a valid state insurance license.

Business EIN(Required)

Business Name(Required)

Business Phone(Required)

Business Principal Agent Name(Required)

First Last

Title(Required)

Business Email(Required)

Company Type(Required)

Sole Proprietorship

C Corporation

S Corporation

Partnership

LLC

LLP

Business Start Date(Required)

MM slash DD slash YYYY

Corporate Address (No PO Boxes)(Required)

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

Individual Resident State License Number(Required)

Individual State License(Required)

Max. file size: 256 MB.

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.

Licenses and Certifications Held(Required)

Life

Health

Both

Legal Questions

1) Past Convictions:(Required)

Yes

Have you ever been charged or convicted of or plead guilty or no contest to any Felony, Misdemeanor, federal/state insurance and/or securities or investments regulations or statuses? Have you ever been on probation?

1A) Felony Conviction:(Required)

Yes

Have you ever been convicted of or plead guilty or no contest to any Felony?

1B) Misdemeanor Conviction:(Required)

Yes

Have you ever been convicted of or plead guilty or no contest to any Misdemeanor?

1C) Securities/Investment Violation:(Required)

Yes

Have you ever been convicted of or plead guilty or no contest to a violation of federal or state securities or investment related regulations?

1D) Insurance Violation:(Required)

Yes

Have you ever been convicted of or plead guilty or no contest to a violation of state insurance department regulations or statutes?

1E) Fraud:(Required)

Yes

Has any foreign government, court, regulatory agency, or exchange ever entered an order against you related to investments or fraud?

1F) Felony Charge:(Required)

Yes

Have you ever been charged with a Felony?

1G) Misdemeanor Charge:(Required)

Yes

Have you ever been charged with a Misdemeanor?

1H) Have you ever been on probation?(Required)

Yes

2) Investigations/Lawsuits:(Required)

Yes

Have you ever been or are you currently being investigated, have any pending indictment, lawsuits, or have you ever been in a lawsuit with an insurance company?

2A) Legal Investigation:(Required)

Yes

Are you currently under investigation by any legal or regulatory authority?

2B) Insurance Investigation:(Required)

Yes

Have you been under investigation by any insurance company?

2C) Legal Proceedings:(Required)

Yes

Have you ever been or are you currently involved in any pending indictments, lawsuits, civil judgments or other legal proceedings? (Civil or criminal only, you may omit family court.)

2D) Lawsuits:(Required)

Yes

Have you ever been named as a defendant or codefendant in a lawsuit, or have you ever sued or been sued by an insurance company?

3) Have you ever been alleged to have engaged in any fraud?(Required)

Yes

4) Have you ever been found to have engaged in any fraud?(Required)

Yes

5) Termination:(Required)

Yes

Has any insurance or financial services company or broker-dealer terminated your contract or appointment or permitted you to resign for reason other than lack of sales?

5A) Termination due to Violation:(Required)

Yes

Were you fired because you were accused of violating insurance or investment related statutes, regulations, rules or industry standards of conduct?

5B) Termination due to Fraud:(Required)

Yes

Were you fired because you were accused of fraud or the wrongful taking of property?

5C) Termination due to Business Quality:(Required)

Yes

Were you fired for failure to supervise in connection with insurance or investment related statutes, regulations, rules, or industry standards of conduct?

6) Denied Applications :(Required)

Yes

Have you ever had an appointment with any insurance company denied or terminated for any cause?

7) Debt:(Required)

Yes

Does any insurer, insured, or other person claim any commission chargeback or other indebtedness from you as a result of any insurance transactions or business?

8) Lawsuits/Claims:(Required)

Yes

Has any lawsuit or claim ever been made against you, your surety company, or errors and omissions insurer arising out of your sales or practices, or have you been refused surety bonding or E&O Coverage?

8A) Bonds:(Required)

Yes

Has a bonding or surety company ever denied, paid on or revoked a bond for you?

8B) E&O:(Required)

Yes

Has any Errors & Omissions (E&O) carrier ever denied, paid claims on or cancelled your coverage?

9) License:(Required)

Yes

Have you ever had an insurance or securities license denied, suspended, cancelled or revoked?

10) Business Restriction:(Required)

Yes

Has any state or federal regulatory body found you to have been a cause of an investment - or insurance - related business having its authorization to do business denied, suspended, revoked, or restricted?

11) Other Licenses:(Required)

Yes

Has any state or federal regulatory agency revoked or suspended your license as an attorney, accountant, or federal contractor?

12) False Statements:(Required)

Yes

Has any state or federal regulatory agency found you to have made a false statement or omission or been dishonest, unfair, or unethical?

13) Have you had any interruptions in licensing?(Required)

Yes

14) Complaints:(Required)

Yes

Has any state, federal or self-regulatory agency filed a complaint against you, fined, sanctioned, censured, penalized or othewise disciplined you for a violation of their regulations or state or federal statutes? Have you ever been the subject of a consumer initiated complaint?

14A) Penalties:(Required)

Yes

Has any regulatory body ever sanctioned, censured, penalized or otherwise disciplined you?

14B) Consumer-Initiated Penalty:(Required)

Yes

Has any state, federal, or self-regulatory agency filed a complaint against you, fined, sanctioned, censured, penalized or othewise disciplined you for a violation of their regulations or state or federal statutes? Have you ever been the subject of a consumer initiated complaint?

14C) Have you ever been the subject of a consumer initiated complaint?(Required)

Yes

15) Bankruptcy:(Required)

Yes

Have you personally or any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or declared bankruptcy?

15B) Firm bankruptcy:(Required)

Yes

Has any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or been declared bankrupt either during your association or within five years after termination of such association?

15C) Is the bankruptcy pending?(Required)

Yes

16) Financial Obligations:(Required)

Yes

Do you have any past due financial obligations unsatisfied judgments, garnishments or liens?

17) Financial Institution Connections:(Required)

Yes

Are you connected in any way with a bank, savings & loan association, or other lending or financial institution?

18) Have you ever used any other names or aliases?(Required)

Yes

Former Name/Alias #1

First Last

Former Name/Alias #2

First Last

19) Do you have any unresolved matters pending with the Internal Revenue Service or other taxing authority?(Required)

Yes

If you answered any questions YES, provide an explanation that includes dates, actions, and descriptions and upload supporting documents.

Yes Answer Explanations

Supporting Documents

Drop files here or

Max. file size: 256 MB.

I attest that the information I have provided is true to the best of my knowledge. I acknowledge that if any information changes, I will notify my agency office by emailing contracting@riversnational.com within 5 days of such change. Further, I understand that my agency may contact me when I need to answer carrier specific questions.

Signature(Required)

Date Signed(Required)

MM slash DD slash YYYY

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.

Account Owner(Required)

First Last

Routing Number(Required)

Account Number(Required)

Financial Institution Name(Required)

Account Type(Required)

Checking

Savings

Voided Check or Direct Deposit Form(Required)

Drop files here or

Max. file size: 256 MB.

I understand that any changes to Direct Deposit information are the responsibility of the agent and must be made directly with the carrier.(Required)

Yes

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.

Signature(Required)

Date Signed(Required)

MM slash DD slash YYYY

Product & Carrier Selection

Life Carriers(Required)

Aetna Life (Includes CVS Accendo & MedSupp)

American Amicable*

Baltimore Life

Combined

Fidelity & Guaranty

Foresters*

Kansas City Life*

Lafayette Life

Mutual of Omaha

National Life Group

Royal Neighbors*

SILAC

Transamerica*

Other

(*) denotes a preferred carrier.
Click Here for Carriers Available in New York
Not seeing a carrier that you're looking for? Please add it in the "Other" box and the Contracting Team will follow up with you by email.

Hidden

MedAdvantage, MedSupp, Cancer, & Rx Plans

Aetna - MedAdvantage & SilverScript

Cigna - MedAdvantage

Humana - MedSupp, MedAdvantage, Dental Vision

Mutual of Omaha - MedSupp, Dental/Vision, Cancer

National Care Dental

UnitedHealthcare (AARP) - MedSupp & MedAdvantage

Wellcare - MedSupp & MedAdvantage

Hidden

Medicare Supplement & Health Carriers That Do Not Require AHIP Certification

Mutual of Omaha (Medicare Supplement, Cancer, & Dental/Vision)

National Care Dental

UnitedHealthcare (AARP) (MedSupp & MedAdvantage with Carrier Certification)

To contract for MedAdvantage and Prescription Plans with more carriers, please select the option above indicating you will certify with AHIP.

UnitedHealthcare Certification Acknowledgement(Required)

Read

Unread

UnitedHealthcare's certification is only valid for UnitedHealthcare products. If later you wish to contract with other carriers for MedAdvantage and Prescription drug plans you will need to certify again via AHIP.

Hidden

Important Medicare Contracting Information

Read

Unread

You will receive an email with additional steps to complete your Medicare contracting if you selected any of the following carriers: Aetna, Cigna, Humana, UnitedHealthcare. Remember to check your spam/junk folder.

American Amicable Anti-Money Laundering Certificate

Max. file size: 256 MB.

AmAm requires their own Anti-Money Laundering training that must be uploaded to submit contracts. Follow this link to complete their course then upload the certificate of completion PDF: https://bit.ly/amamaml

Do you also want to sell MOO Health Products?(Required)

Yes

Selecting "Yes" will get you set up to sell Cancer, Critical Illness, Dental/Vision, and Medicare Supplement policies.

Mutual of Omaha Agent Agreement Consent(Required)

Yes

Click to open and review the Mutual of Omaha Agent Agreement

Do you have an existing writing number with Mutual of Omaha?(Required)

Yes

Mutual of Omaha Agent Writing Number(Required)

I will verify with Mutual of Omaha that my contract is eligible to move and submit carrier release forms if necessary.(Required)

Yes

I will verify with Mutual of Omaha that my contract has been completly processed for all the desired products before submitting new business.(Required)

Yes

Do you have an existing writing number with National Life Group?

Yes

NLG Agent Writing Number(Required)

Required NLG Transfer Form(Required)

Drop files here or

Max. file size: 256 MB.

Download, complete and sign the required NLG Transfer Form. Only your signature is required unless you need a release from your previous upline to move your contract. If you're not sure if you need your former upline's signature to transfer, you can call NLG directly and they will let you know: (800) 906-3310.

It is NLG policy, not Partners Life, to freeze an agent's commission level for one year following the transfer of their contract to a new agency.(Required)

It is NLG policy, not Partners Life, to freeze an agent's commission level for one year following the transfer of their contract to a new agency.

Do you have an existing writing number with Transamerica?(Required)

Yes

Transamerica Agent Writing Number(Required)

Required Transamerica New Business(Required)

Drop files here or

Max. file size: 256 MB.

Proof of new business is required for either transfer or multiple relationship requests. Please upload completed client paper application for insurance.

Required Transamerica Transfer Form(Required)

Drop files here or

Max. file size: 256 MB.

Download, complete and sign the required Transamerica Transfer Form. Only your signature and information on new business you're submitting is required.

American Amicable Anti-Money Laundering Certificate(Required)

Drop files here or

Max. file size: 256 MB.

AmAm requires their own Anti-Money Laundering training that must be uploaded to submit contracts. CLICK HERE to complete their course then upload the certificate of completion PDF.

Required New Business(Required)

Drop files here or

Max. file size: 256 MB.

A new client application for insurance is required to contract with Allianz, Ameritas, Athene, Nassau RE, National Western, North American, and Sagicor.

Authorization to Submit Contracts and Disclosures

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

It can take up to 2 full business days from the time all necessary documents are received for requests to be processed and are worked in the order they are received.(Required)

It can take up to 2 full business days from the time all necessary documents are received for requests to be processed and are worked in the order they are received.

Contracts will be created and submitted to insurance carriers on my behalf.(Required)

Contracts will be created and submitted to insurance carriers on my behalf.

The contracting links received from each of the carriers I selected are only valid for 30 days and must be completed promptly.(Required)

The contracting links received from each of the carriers I selected are only valid for 30 days and must be completed promptly.

I must respond and reply directly to the carrier for all contracting requirements and conditions.(Required)

I must respond and reply directly to the carrier for all contracting requirements and conditions.

I must respond directly to the carrier when they ask me to provide my Anti-Money Laundering (AML) Certification.(Required)

I must respond directly to the carrier when they ask me to provide my Anti-Money Laundering (AML) Certification.

AHIP certification is required for MA/PDP sales. A $50 discount can be accessed through the carriers' certification portals.(Required)

AHIP certification is required for MA/PDP sales. A $50 discount can be accessed through the carriers' certification portals.

It is the agent's responsibility to follow up with the carrier on contract requests once they've been submitted.(Required)

It is the agent's responsibility to follow up with the carrier on contract requests once they've been submitted.

Before writing business with a carrier that I was previously contracted with, I will call the carrier and verify my contract has been updated for the product I am writing.(Required)

Before writing business with a carrier that I was previously contracted with, I will call the carrier and verify my contract has been updated for the product I am writing.

It is the agent's responsibility to track and maintain all licenses, certifications, carrier appointments, and Errors & Omissions.(Required)

It is the agent's responsibility to track and maintain all licenses, certifications, carrier appointments, and Errors & Omissions.

I will be receiving training announcements by text and email. I can opt out at any time by clicking "unsubscribe" or replying "stop" to messages.(Required)

I will receiving training announcements by text and email. I can opt out at any time by clicking "unsubscribe" or replying "stop" to messages.

Releases are granted by Rivers National immediately upon request but are still subject to processing, carrier policies, and blackout dates. Partners Life and affiliates reserve the right to deny release requests if there is any existing carrier debt.(Required)

Releases are granted by Partners Life immediately upon request but are still subject to processing, carrier policies, and blackout dates. Partners Life and affiliates reserve the right to deny release requests if there is any existing carrier debt.

I hereby authorize Rivers National LLC, their affiliates, and SuranceBay, LLC to affix or append a copy of my signature, as set forth below, to any and all required signature fields on forms and agreements of any insurance carrier designated by or for me through the SureLC software or through any other means, including without limitation, by email or orally. The Authorized Parties shall be permitted to complete and submit all such forms and agreements on my behalf for the purpose of becoming authorized to sell Carrier insurance products. I hereby release, indemnify and hold harmless the Authorized Parties against any and all claims, demands, losses, damages, and causes of action, including expenses, costs and reasonable attorneys' fees which they may sustain or incur as a result of carrying out the authority granted hereunder. By my signature below, I certify that the information I have submitted to the Authorized Parties is correct to the best of my knowledge and acknowledge that I have read and reviewed the forms and agreements which the Authorized Parties have been authorized to affix my signature. I agree to indemnify and hold any third party harmless from and against any and all claims, demands, losses, damages, and causes of action, including expenses, costs and reasonable attorneys' fees which such third party may incur as a result of its reliance on any form or agreement bearing my signature pursuant to this authorization.