Insurance Professional Application

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Insurance Professional Application

Our objective at the Retirement Education and Resource Center of North America, Inc. (RERCNA) is transparency of individuals that meet and represent the opinions and guidelines within Positioning 4 Retirement, allowing the reader a basis for selecting a team of professionals.

By completing and signing this application, it allows RERCNA an opportunity to contact and discuss your professional and personal character as presented in your answers to the questions. You agree to hold Positioning 4 Retirement and its entities and administrators harmless of incident or issues that may arise due to the completion of this application.

Fields marked with * are required.

GEOGRAPHICAL PREFERENCE

What geographical area would you like to represent? Please list general area(s) such as Boston, Cape Cod, western or central Massachusetts, etc...:*

Please list at least one area you would like to represent.

CONTACT INFORMATION

First name:*

Please include attorney's full name.

Last name:*

Please include attorney's full name.

Firm Name:*

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Full business address:*

Please include business address

Office phone number:*

Please include office phone number.

Mobile phone number:

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Email address:*

Please enter a valid email address

Website address:

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PROFESSIONAL INFORMATION

licenses

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State(s) licensed: (hold Ctrl+ key to select more than one.)*

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Professional designations

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How many years have you been practicing?*

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What type of agent are you?

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If you work for or represent a financial institution (bank, investment company, insurance agency, etc.), what is the name and web address of the institution?

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May we contact the institution to discuss your position with them?

Yes No Invalid Input

What insurance company or companies do you represent? Please list them:

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If you have a general agent, please list:

Name of general agent:

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Phone no. of general agent:

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Agency represented by general agent:

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FIRM INFORMATION

If you are a member of a firm or agency, how many insurance professionals are there?

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Do the other insurance professionals review your work and do you review theirs?

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If you are a member of a firm, how many of the following are in your firm?

Attorneys:

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CPAs:

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Investment Professionals:

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ONGOING EDUCATION AND LEVELS OF ACHIEVEMENT

What professional designations does the agent have?

CLU (Certified Life Underwriter) ChFC (Chartered Financial Consultant) CFP (Certified Financial Planner) CLTC (Certified Long Term Care) RHU (Registered Health Underwriter) LUTCF (Life Underwriter Training Council Fellow) Other Invalid Input

If other, please list:

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List continuing education courses taken in the past 3 years. Include courses that do not offer CE credits. Include, course title, instructor, organization offering course, and a brief description.

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PRODUCT REPRESENTATION AND FOCUS

Please breakdown each line of insurance you represent by volume. (For example: Life Insurance: Term 10%, UL 90 %, Whole 0%; Annuities: Deferred 50%, Indexed 20%, Immediate 30%, Variable 0%.)

Life Insurance

% Term

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% UL

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% Whole Life

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Disability

% Short-term

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% Mid-term

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% Long-term

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Life Insurance

% Comprehensive/Stand-alone

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% In-home Care

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% Skilled Care

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Annuities

% Immediate

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% Fixed Index

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% Fixed Deferred

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% Variable

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Are you a registered securities representative?

Yes No Invalid Input

If yes, complete an additional application as an - Investment Professional.”
If yes, considering the total volume of business your practice performs, what is the percentage breakdown of the following (the total should equal 100%):

% Securities

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% Insurance Products

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% Other (also provide detail)

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YOUR TEAM OF PROFESSIONALS

Do you currently have an organized team of professionals?

Yes No Invalid Input

It is not necessary for you to have an assembled team; however, if you have a team or a partial team, we would like to know.

Please provide us a list of any professionals on your team and include their area of expertise (attorney, CPA, investment advisor, or insurance advisor), their website url, and whether or not they have applied to P4R (if known.)

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Additional Comments

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DISCLAIMER

It is RERCNA’s objective to seek transparency within the individuals that meet and represent the opinions and guidelines within the book, Positioning 4 Retirement, allowing the reader a basis for selecting a team of professionals.

By checking the agreement below, you allow RERCNA to contact and discuss your professional and personal character as presented in your answers to the above questions. You also agree to hold RERCNA, its affiliates, website partners, publication partners, and other team members harmless from and against any loss, incidental, special or consequential damage, liability, cost, or expense for any negligent or wrongful act or omission or misrepresentation by RERCNA relating to the information from this application or any of its links including, without limitation, reasonable attorney’s fees.

Checking the box below constitutes an electronic signature:*

I agree to the above disclaimer and the terms & conditions of Positioning4Retirement.com. You must verify that you agree to the terms and conditions by checking this box to proceed.

Contact Info

Phone: 781-763-RERC (7372)

Mailing Address:

RERCNA
Dedham Place
3 Allied Drive Suite 303
Dedham, Massachusetts 02026