| Section Name | Field Name | Field and/or Section Description |
| TITLE ACORD 758 (2011/03) | Life, Annuity and Health Producer Appointment Form | ACORD 758, Life, Annuity and Health Producer Appointment Form, is a standard Producer Appointment Form, accepted by multiple carriers. This form is used to initiate the relationship between the Producer and the Carrier. This form is to be completed by a Producer and then sent to the new Carrier. Not all features and benefits offered on this application are available with each carrier’s life insurance plans. Be sure to contact your agent or the underwriting carrier to verify the specific benefits available in the plan for which the proposed insured is applying. |
| IDENTIFICATION SECTION | Name of Insurance Company Must be Inserted Before This Form Is Used | Name and address of Insurance Company. Use the actual name of the company. Do not use group names. |
| 1. FORM PURPOSE | Form Purpose | Indicate the purpose of the form. |
| 1. FORM PURPOSE | Check Box – New Appointment | Check the appropriate box to indicate. |
| 1. FORM PURPOSE | Check Box – Change | Check the appropriate box to indicate. |
| 1. FORM PURPOSE | Check Box –TerminationAppointment | Check the appropriate box to indicate. |
| 1. FORM PURPOSE | Check Box – Additional Appointment | Check the appropriate box to indicate. |
| 2. PRODUCER INFORMATION | First Name | First name of the producer. |
| 2. PRODUCER INFORMATION | Middle Name | Middle name of the producer. |
| 2. PRODUCER INFORMATION | Last Name | Last name of the producer. |
| 2. PRODUCER INFORMATION | Designations | Indicate the designations of the producer. |
| 2. PRODUCER INFORMATION | Legal Residence (No P.O. Box) Line 1 | Indicate the legal residence of the producer. Do not use P.O. Box number. Check if this address is the preferred method of mailing. |
| 2. PRODUCER INFORMATION | Line 2 | Residence address – Line 2. |
| 2. PRODUCER INFORMATION | City | Indicate the city of the address. |
| 2. PRODUCER INFORMATION | State | State of the address. |
| 2. PRODUCER INFORMATION | Zip | Zip code, postal code, etc. (country dependent) |
| Section Name | Field Name | Field and/or Section Description |
|---|---|---|
| 2. PRODUCER INFORMATION | Date of Birth | Indicate the date of birth of the producer in MM/DD/YYYY format. |
| 2. PRODUCER INFORMATION | SSN # / Gov’t ID | Social security number or Government Identification Number of producer. |
| 2. PRODUCER INFORMATION | National Producer Number | Enter the National Producer Number assigned by the NAIC. |
| 2. PRODUCER INFORMATION | Business Name | Indicate the business name of the producer. |
| 2. PRODUCER INFORMATION | Business Address Line 1 | Indicate the business address of the producer. Check if this address is the preferred method of mailing. |
| 2. PRODUCER INFORMATION | Line 2 | Business Address Line 2 |
| 2. PRODUCER INFORMATION | City | Indicate the city of the address. |
| 2. PRODUCER INFORMATION | State | State of the address. |
| 2. PRODUCER INFORMATION | Zip | Zip code, postal code, etc. (country dependent) |
| 2. PRODUCER INFORMATION | FEIN | Enter the FederalEmployer Identification Number (FEIN) of the business. |
| 2. PRODUCER INFORMATION | Business Phone | Indicate the business phone number of the producer, including area code and extension (if applicable). |
| 2. PRODUCER INFORMATION | Business Fax | Indicate the business phone number of the producer, including area code. |
| 2. PRODUCER INFORMATION | Website Address | The URL (website) address of the producer. |
| 2. PRODUCER INFORMATION | Business e-mail Address | Enter the e-mail address pertaining to the producer. |
| 2. PRODUCER INFORMATION | Have you used any other names or aliases? | If “YES”, please list any/all such names. |
| 2. PRODUCER INFORMATION | Prefix | Enter any phrase to precede the name which is not part of the actual name, such as Dr. or Mrs. |
| 2. PRODUCER INFORMATION | First Name | Enter the individual’s “first name”. |
| 2. PRODUCER INFORMATION | Middle Name | Enter the individual’s “middle name”. |
| Section Name | Field Name | Field and/or Section Description |
|---|---|---|
| 2. PRODUCER INFORMATION | Surname | Enter the individual’s surname, also known in the USA as “Last Name”. |
| 2. PRODUCER INFORMATION | Suffix | Enter any applicable suffix. For example, “Jr.”, or “III”. |
| 2. PRODUCER INFORMATION | Check box – Alias | Check the applicable box. |
| 2. PRODUCER INFORMATION | Check box – Maiden | Check the applicable box. |
| 2. PRODUCER INFORMATION | Check box – Previous | Check the applicable box. |
| 3 BROKER / DEALER INFORMATION | Broker / Dealer Name | Indicate the business name of the broker / dealer. (This section is only applicable if you are a Broker / Dealer.) |
| 3 BROKER / DEALER INFORMATION | Broker / Dealer Address Line 1 | Indicate the business address of the broker/dealer. |
| 3 BROKER / DEALER INFORMATION | Line 2 | Business Address Line 2 |
| 3 BROKER / DEALER INFORMATION | City | Indicate the city of the address. |
| 3 BROKER / DEALER INFORMATION | State | State of the address. |
| 3 BROKER / DEALER INFORMATION | Zip | Zip code, postal code, etc. (country dependent) |
| 3 BROKER / DEALER INFORMATION | Tax ID | Tax Identification Number of the broker/dealer. |
| 3 BROKER / DEALER INFORMATION | Phone # | Indicate the business phone number of the broker/dealer, including area code and extension (if applicable). |
| 3 BROKER / DEALER INFORMATION | Fax # | Indicate the business fax number of the broker/dealer, including area code. |
| 3 BROKER / DEALER INFORMATION | Broker / Dealer CRD # | Registration number issued to a distributor by the NASD. |
| 4. APPOINTMENT INFORMATION | Type of Appointment | Check the appropriate box to indicate type of appointment. |
| 4. APPOINTMENT INFORMATION | Check Box – Individual | Check the appropriate box to indicate type of appointment. |
| 4. APPOINTMENT INFORMATION | Check Box – Firm / Agency | Check the appropriate box to indicate type of appointment. |
| Section Name | Field Name | Field and/or Section Description |
| 4. APPOINTMENT INFORMATION | Is Firm / Agency Incorporated? | Check the applicable box. If incorporated, indicate type of corporation. |
| 4. APPOINTMENT INFORMATION | Check Box – Sole Proprietor | Check the appropriate box to indicate what type of corporation the business is. |
| 4. APPOINTMENT INFORMATION | Check Box – S-Corporation | Check the appropriate box to indicate what type of corporation the business is. |
| 4. APPOINTMENT INFORMATION | Check Box – LLC | Check the appropriate box to indicate what type of corporation the business is. |
| 4. APPOINTMENT INFORMATION | Check Box – LLP | Check the appropriate box to indicate what type of corporation the business is. |
| 5. COMMISSION HIERARCHY | Brokerage General Agency Name (BGA) | The name of the Brokerage General Agency (BGA). |
| 5. COMMISSION HIERARCHY | BGA Number | The identification number of the Brokerage General Agency (BGA). |
| 5. COMMISSION HIERARCHY | General Agent | The name of the General Agent. |
| 5. COMMISSION HIERARCHY | Agency Name | The name of the Agency. |
| 6. EMPLOYMENT HISTORY | If you have been employed anywhere other than with your current employer in the last seven (7) years, list here. For additional information please use the Remarks section. | |
| 6. EMPLOYMENT HISTORY | Current Employer Name | Enter the name of the employer. |
| 6. EMPLOYMENT HISTORY | CurrentEmployer Address Line 1 | Indicate the address of the employer. |
| 6. EMPLOYMENT HISTORY | Line 2 | Business Address Line 2. |
| 6. EMPLOYMENT HISTORY | City | Indicate the city of the address. |
| 6. EMPLOYMENT HISTORY | State | State of the address. |
| 6. EMPLOYMENT HISTORY | Zip | Zip code, postal code, etc. (country dependent) |
| 6. EMPLOYMENT HISTORY | Start Date | The first date this employment was effective. |
| Section Name | Field Name | Field and/or Section Description |
| 6. EMPLOYMENT HISTORY | Previous Employer Name | Indicate the name of the previous employer. |
| 6. EMPLOYMENT HISTORY | Previous Employer Address Line 1 | Indicate the address of the previous employer. |
| 6. EMPLOYMENT HISTORY | Line 2 | Business Address Line 2. |
| 6. EMPLOYMENT HISTORY | City | Indicate the city of the address. |
| 6. EMPLOYMENT HISTORY | State | State of the address. |
| 6. EMPLOYMENT HISTORY | Zip | Zip code, postal code, etc. (country dependent) |
| 6. EMPLOYMENT HISTORY | Start Date | The first date this employment was effective. |
| 6. EMPLOYMENT HISTORY | End Date | The last date this employment was effective. |
| 7. LICENSE INFORMATION | License Information | If appointment is requested, please indicate the line requested. For non-resident appointment in Florida, indicate counties in which you want to be appointed. A nonresident form is required in Hawaii. |
| 7. LICENSE INFORMATION | Resident License State | Resident state the license was issued in. Indicates if the producer is a resident of the state that issued the license. |
| 7. LICENSE INFORMATION | Resident License Number | Resident state license number. |
| 7. LICENSE INFORMATION | Resident License Line of Business | Indicate Resident License Line of Business. |
| 7. LICENSE INFORMATION | Appointment Requested / Line of Business | Indicate Appointment Requested / Line of Business. |
| 7. LICENSE INFORMATION | Non-Resident License State | Non-Resident state the license was issued in. |
| 7. LICENSE INFORMATION | Non-Resident License County | Non-Resident county the license was issued in. |
| 7. LICENSE INFORMATION | Non-Resident License Number | Non-Resident state license number. |
| 7. LICENSE INFORMATION | Non-Resident License Line of Business | Indicate Non-Resident License Line of Business. |
| Section Name | Field Name | Field and/or Section Description |
| 7. LICENSE INFORMATION | Appointment Requested / Line of Business | Indicate Appointment Requested / Line of Business. |
| 8. NASD LICENSE INFORMATION | Are you NASD licensed / registered | Check the appropriate box to indicate whether or not you are NASD licensed. If “YES”, indicate what type of license you have. |
| 8. NASD LICENSE INFORMATION | Series 6 | Check the applicable box. |
| 8. NASD LICENSE INFORMATION | Series 7 | Check the applicable box. |
| 8. NASD LICENSE INFORMATION | Series 63 | Check the applicable box. |
| 8. NASD LICENSE INFORMATION | Other | Check the applicable box. If OTHER, identify. |
| 8. NASD LICENSE INFORMATION | Broker / Dealer Affiliation | Enter the Broker or Dealer with whom you are affiliated. |
| 8. NASD LICENSE INFORMATION | Individual CRD # | CRD number – Registration number issued to a Distributor by the NASD. |
| 9. E & O Policy Information | Policy Amount | Indicate the amount of the E&O coverage. |
| 9. E & O Policy Information | Policy Number | Indicate the policy number. |
| 9. E & O Policy Information | Policy Carrier | Indicate the name of the insurance carrier. Use the actual name of the company. Do not use group names. |
| 9. E & O Policy Information | Effective Date | Enter the date on which the policy commenced. (MM/DD/YYYY) |
| 9. E & O Policy Information | Expiration Date | Enter the date on which the policy will terminate, unless renewed. (MM/DD/YYYY) |
| 10. BUSINESS PRACTICES | Business Practices | Enter Y for a “YES” response or N for a “NO” response, to the questions regarding your Business Practices. If you answer “YES” to any of these questions, attach a signed written explanation with all relevant information and supporting documents. |
| 10. BUSINESS PRACTICES | 1. Have you ever had an insurance license or appointment, or a securities registration, or an application for such, denied, suspended, cancelled or revoked? | Enter Y for a “YES” response. Enter N for a “NO” response. If you answer “YES” to any of these questions, attach a signed written explanation with all relevant information and supporting documents. |
| Section Name | Field Name | Field and/or Section Description |
| 10. BUSINESS PRACTICES | 2. Has any legal or regulatory body ever sanctioned, censured, penalized or otherwise disciplined you? | Enter Y for a “YES” response. Enter N for a “NO” response. If you answer “YES” to any of these questions, attach a signed written explanation with all relevant information and supporting documents. |
| 10. BUSINESS PRACTICES | 3. Has any state or federal regulatory agency or self-regulatory authority ever filed a complaint against you? | Enter Y for a “YES” response. Enter N for a “NO” response. If you answer “YES” to any of these questions, attach a signed written explanation with all relevant information and supporting documents. |
| 10. BUSINESS PRACTICES | 4. Have you ever been subject to an insurance or investment related consumer initiated complaint or proceeding? | Enter Y for a “YES” response. Enter N for a “NO” response. If you answer “YES” to any of these questions, attach a signed written explanation with all relevant information and supporting documents. |
| 10. BUSINESS PRACTICES | 5. Has a bonding or surety company denied, ever paid out on, or revoked a bond for you? | Enter Y for a “YES” response. Enter N for a “NO” response. If you answer “YES” to any of these questions, attach a signed written explanation with all relevant information and supporting documents. |
| 10. BUSINESS PRACTICES | 6. Has an E & O carrier ever denied claims, paid claims, or cancelled your coverage? | Enter Y for a “YES” response. Enter N for a “NO” response. If you answer “YES” to any of these questions, attach a signed written explanation with all relevant information and supporting documents. |
| 10. BUSINESS PRACTICES | 7. Have you individually, or has a company you exercised control over, filed a bankruptcy petition or been the subject of an involuntary bankruptcy petition? | Enter Y for a “YES” response. Enter N for a “NO” response. If you answer “YES” to any of these questions, attach a signed written explanation with all relevant information and supporting documents. |
| 10. BUSINESS PRACTICES | 8. Are there are any unsatisfied judgements, garnishments or liens against you? | Enter Y for a “YES” response. Enter N for a “NO” response. If you answer “YES” to any of these questions, attach a signed written explanation with all relevant information and supporting documents. |
| 10. BUSINESS PRACTICES | 9. Are you in debt to any insurance company? | Enter Y for a “YES” response. Enter N for a “NO” response. If you answer “YES” to any of these questions, attach a signed written explanation with all relevant information and supporting documents. |
| 10. BUSINESS PRACTICES | 10. Have ever been indicted for, convicted of or pled guilty or nolo contendre to any felony or misdemeanor other than a minor traffic offense? | Enter Y for a “YES” response. Enter N for a “NO” response. If you answer “YES” to any of these questions, attach a signed written explanation with all relevant information and supporting documents. |
| Section Name | Field Name | Field and/or Section Description |
| 10. BUSINESS PRACTICES | 11. Are you currently party to any litigation or the subject of any investigations? | Enter Y for a “YES” response. Enter N for a “NO” response. If you answer “YES” to any of these questions, attach a signed written explanation with all relevant information and supporting documents. |
| 10. BUSINESS PRACTICES | Name (Please Print) | Print or type the full name of the producer. |
| 10. BUSINESS PRACTICES | Signature | The producer must sign this form. |
| 10. BUSINESS PRACTICES | Date | Enter date the form was signed by the producer. |
| 11. AUTHORIZATION | For *California, Minnesota and Oklahoma Applicants Only | Enter this information only for the states of California, Minnesota and Oklahoma. |
| 11. AUTHORIZATION | Company Name | Enter the name of the company obtaining the consumer credit report. |
| 11. AUTHORIZATION | Street Address | Enter the street address of the company obtaining the consumer credit report. |
| 11. AUTHORIZATION | City | Enter the city address of the company obtaining the consumer credit report. |
| 11. AUTHORIZATION | State | Enter the state address of the company obtaining the consumer credit report. |
| 11. AUTHORIZATION | Zip Code | Enter the zip code of the company obtaining the consumer credit report. |
| 11. AUTHORIZATION | Consumer Credit Report Yes/No | Applicant must initial whether or not they choose to receive a copy of the consumer credit report. |
| 11. AUTHORIZATION | Investigative Consumer Report and/or Consumer Report Yes/No | Applicant must initial whether or not they choose to receive a copy of the investigative consumer report and/or consumer report. |
| 11. AUTHORIZATION | Name (Please Print) | Print or type the full name of the producer. |
| 11. AUTHORIZATION | Signature | The producer must sign this form. |
| 11. AUTHORIZATION | Date | Enter date the form was signed by the producer. |
| 12. REMARKS | Remarks | Use this space for any additional remarks. |