Gerber Life Insurance Company Contracting Application

Legal Name
First:* Middle: Last:*

Home Address

Line 1:*

City: * State:* County: Zip:*

Home Phone:*
(format 123-456-7890)

Business Phone:
(format 123-456-7890)

Fax:
(format 123-456-7890)

Email:*

Cell Phone:
(format 123-456-7890)

Background Experience. Note: Please read each question carefully. failure to answer "Yes" below, when appropriate, may result in the denial of your request to be contracted.

1. Have you ever been finished, suspended, placed on probation, paid administrative costs, entered into a consent order, been issued a restricted licence or or otherwise been disciplined or reprimanded, or are you currently under investigation by any insurance department, FINRA (formerly known as the NASD), SEC or any other regulatory authority?otherwise been disciplined or reprimanded, or are you currently under investigation by any insurance department, FINRA (formerly known as the NASD), SEC or any other regulatory authority? *

Yes

No

2. Have you ever been convicted or plead guilty or nolo contendere (no constest), served any probation, paid any fines or court costs, had dismissed through any type of first offender or deferred adjudication or suspended sentence procedure, or are any charges currently pending against you for any offense other than a minor traffic voilation? *

Yes

No

Check Deposit Authorization *

I, the undersigned, do hereby authorize Gerber Life Insurance Company to deposit my check as indicated below. This authority is to remain in full force and effect until Gerber Life Insurance Company has received notification from me of its termination in such time and in such manner as to afford Gerber Life Insurance Compny a reasonable opportunity to act on it.In no event shall it be effective with respect to entries processed prior to receipt of notice of termination

I understand, this is not an assignment of commisssions.1099's will continue to be issued to the commisssion owner.

New Deposit

Change Deposit

Account Number

Checking Account

Saving Account

This electronic deposit is for (check one): *

Company

individual

Selection Mode of Advance (Please select one mode of advance from the choices below) by initialing under your selection. All choices are for advance of commission upon the issuance of an eligible Product. *

Six-Month(QD2)

Nine-Month(QD3)

Twelve-Month(QD4)

General Agent Full Name:*

General Agent Title:

Designated Benficiary:

Social Security Number:*
(Numbers only - e.g. 123456789)

Employer Identification Number:

Producer Number
(format 123-456-7890)

Lookup NPR#:

Date of Birth:*
(mm/dd/yyyy)

Your signature:*

Preview:

For California, Minnesota and Oklahoma: You have a right to request a copy of the consumer report which will disclose the nature and scope of the report.
Yes, please provide me a copy of the consumer report

By checking below I certify that all information contained in this document is accurate and can be considered legally binding. *
I agree