Woodmen of the World / Assured Life Association Contracting Application

Legal Name

First:* Middle: Last:*

Home Address

Line 1:*

City: * State:* Country: Zip:*

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

Business Phone:
(format 123-456-7890)

Home Fax:
(format 123-456-7890)

Busines Fax:
(format 123-456-7890)

Email:*

Cell Phone:
(format 123-456-7890)

Producer No:
(format 123-456-7890)

Lookup NPR#:

Busines Name:

Personal Busines Address:
(*Note - All correspondence (including compensation statements), will be mailed to the personal business address indicated. Only one business address is supported per individual. If no business address is indicated, mail will be directed to home address.)

Address for overnight Packages(can not be a P.O. Box)

Please identify your master agency(if applicable)

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 fined, suspended, placed on probation, paid administrative costs, entered into a consent order, been issued a restricted license 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?*

Yes

No

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

Yes

No

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 date and sign the written statement.

Check Deposit Authorization

I hereby undersigned, authorize Woodmen of the World/Assured Life Association to deposit my check as indicated below. This authority has to remain in full force and effect until Woodmen of the World/Assured Life Association has received notification from me of its termination in such time and in such manner as to afford Woodmen of the World/Assured Life Association a reasonable opporutnity 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 commissions. 1099's will continue to be issued to the commission owner.

AVOIDED CHECK MUST BE ATTACHED TO VERIFY ACCOUNT NUMBER

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(QB1)

Nine-Month(QB2)

Tweleve-Month(QB3)

General Agent Full Name:*

General Agent Title:

Designated Benficiary:

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

Employer Identification Number:
(Numbers only - e.g. 123456789)

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

Your signature:*

Preview:

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