Pre Requirements

To complete this form, make sure you have these items readily available

Personal information Including Social Security Number, Date of Birth, Current Address
Designation of Commissions: As Earned (Month to Month) or Advanced
Proof of current Errors and Omissions Coverage
Anti-Money Laundering Certificate (If Selling ANY Life Insurance)
Valid Voided Check or EFT form to set up your Bank deposits. (Not required for Licensed Only Agents, LOA)
Supporting documents required for background questions
CMS/FFM Certification is required BEFORE requesting any Affordable Care Act (ACA) Carriers.
AHIP Certification is required BEFORE requesting any Medicare Carriers. (Discount with Aetna provided below)

If Doing Business as an Agency or LLC

Business needs to be licensed and registered with NIPR.
Business EIN and National Producer Number

Bank Authorization

Electronic Funds Transfer Agreement: 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.

TCPA Consent.I consent and approve of receiving calls, SMS messages (including text messages) and emails from Ally Health Group, their affiliated companies, or their agents, representatives, or affiliates or anyone calling on their behalf for any and all purposes arising out of or relating to our mutual relationship, at any telephone number, or physical or email or electronic address you provide us or at which you may be reached. Telephone numbers you provide include those you give to us, those from which you or others contact us, or which we obtain through other means. You agree we may contact you in any way, including SMS messages (including text messages) calls using pre-recorded messages or artificial voice, and calls and messages delivered using automatic telephone dialing systems (auto‐dialer) or an automatic texting system. Automated messages may be played when the telephone is answered, whether by you or someone else. In the event that an agent or representative calls, he/ she may also leave a message on your answering machine, voice mail, or send one via text. Ally Health Group, OUR AGENTS, REPRESENTATIVES, AFFILIATES AND ANYONE CALLING ON OUR BEHALF MAY USE SUCH MEANS OF COMMUNICATION DESCRIBED IN THIS SECTION. *

I agree to the terms & conditions.

Agent Agreement *

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 within 5 days of such change. Further, I understand that my agency may contact me when I need to answer specific questions. I further understand and agree that this form and the information contained herein will be shared with First Heartland Corporation, its affiliated companies, and any other organization, entity, or person with whom I am seeking licensure, registration, or appointment. *

Sign here *

Clear

Signature Authorization. PLEASE READ THIS AUTHORIZATION, SIGN IN THE BOX BELOW AND SUBMIT THIS FORM BY FOLLOWING THE INSTRUCTIONS PROVIDED ON THE COVER PAGE. I hereby authorize SuranceBay, LLC, its general agency customers, and First Heartland® (the “Authorized Parties”) 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 (a “Carrier”) designated by me through SureLC software or through any other means, including without limitation, by e-mail 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 attorney’s 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 to 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 attorney’s 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. Please sign in the center of the box below. *