Contracting Request

First Name *

Last Name *

Email *

Phone *

Type of Request?

New Agent - Onboarding

Existing Agent - Adding a New Carrier

Existing Agent - Compensation or Hierarchy Change

What States Are You Licensed In? *

City *

State *

Postal code *

What products are you interested in? *

Are you contracting as an individual or agency? *

Independent Agent

BBI LOA Career Agent

Agency with Independent Downlines

Agency with LOA Agents

Agency with LOA's & Independet Downlines

Agency Name *

Agency NPN *

Agency TIN *

Medicare Advantage Requests

Medicare Supplement Requests

Life Insurance Requests

Ancillary Requests

ACA Requests

Annuity Requests

Any carrier not listed that you would like to contract with?

Bank Name *

City and State of Bank *

Routing Number *

Account Number *

Voided Check *

Upload copy of a Voided Check

E&O Carrier Name *

E&O Policy Number *

E&O Certificate Copy *

Upload your E&O Certificate

Will you need to be released from any other upline/FMO? *

Letter of Release or Intent to Release (if immediate upline is not releasing)

Upload Release Letters for EACH Carrier

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 and statutes? Have you ever been on probation?

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

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

Additional Contracting Notes (Optional)

Contracting Authorization

I hereby authorize Safe Harbor Insurance Inc and its general agency customers (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 the Safe Harbor Insurance 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 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. Please sign in the center of the box below.

Signature *

Clear

Printed Name *

Date *

Mother's Maiden Name *

Contracting Request

Before you begin, make sure you have the following items available:

VOIDED CHECK

E&O CERTIFICATE

TAX ID NUMBER

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