Insurance Professional Application

Page 1 of 4

Investment 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:*

Invalid Input

Full business address:*

Please include business address

Office phone number:*

Please include office phone number.

Mobile phone number:

Invalid Input

Email address:*

Please enter a valid email address

Website address:

Invalid Input

PROFESSIONAL INFORMATION

licenses

Invalid Input

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

Invalid Input

Professional designations

Invalid Input

How many years have you been practicing?*

Invalid Input

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?

Invalid Input

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

Yes No Invalid Input

What investment and/or insurance company(s) do you represent? Please list them:

Invalid Input

If you have a general agent, please list:

If you have a general agent/brokerage firm, please list:

Name of general agent:

Invalid Input

Phone no. of general agent:

Invalid Input

Agency/firm represented by general agent:

Invalid Input

FIRM INFORMATION

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

Investment professionals:

Invalid Input

Insurance Professionals:

Invalid Input

What is the firm’s CRD number?

Invalid Input

What is the advisor’s CRD number?

Invalid Input

If other investment professionals in your firm, do the other investment professionals review your work and do you review theirs?

Invalid Input

How many of the following are in your firm?

Attorneys:

Invalid Input

CPAs:

Invalid Input

Insurance Professionals:

Invalid Input

Investment Professionals:

Invalid Input

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:

Invalid Input

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.

Invalid Input

PRODUCT REPRESENTATION AND FOCUS

What products do you represent and what dollar volume and percentage of the product make up your book of business? (ex. stocks, bond, mutual funds, etc... list each product on it's own line, e.g. Stocks | $20,000,000 | 40%)

Invalid Input

Please explain any programs you offer that may be unique.

Invalid Input

INSURANCE 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

Invalid Input

% UL

Invalid Input

% Whole Life

Invalid Input

Disability

% Short-term

Invalid Input

% Mid-term

Invalid Input

% Long-term

Invalid Input

Life Insurance

% Comprehensive/Stand-alone

Invalid Input

% In-home Care

Invalid Input

% Skilled Care

Invalid Input

Annuities

% Immediate

Invalid Input

% Fixed Index

Invalid Input

% Fixed Deferred

Invalid Input

% Variable

Invalid Input

COMPENSATION

How much of your compensation comes from each category? The two should add to 100%.

% Fee

Invalid Input

% Commission

Invalid Input

Please list your services and fees:

Invalid Input

TEAM MEMBERS

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.)

Invalid Input

Additional Comments

Invalid Input

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