Agency Data (Complete only if an Agency is being contracted) 

License data enclose a current copy of each state agent/agency insurance license (life and health) under which you will be selling Sentinel Security Life products.

I will promptly notify Sentinel Security Life Insurance Company and its affiliates of any cancellation or major modifications to my coverage.

General Information Please respond to all questions for you personally and any organization over which you have
exercised control. If you answer “Yes” to any questions, you must attach an additional sheet explaining all relevant information
and include supporting documents.

PROVIDE A WRITTEN EXPLANATION AND APPLICABLE SUPPORTING DOCUMENTATION (i.e. court documents, insurance department documents, etc.) FOR ANY QUESTION TO WHICH YOU RESPONDED "YES". Please be sure to sign the written statement.

Check Deposit Authorization

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

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

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