Online Contracting – Pinnacle Financial Services

Online Contracting

Welcome - Step 1 of 9

Welcome

To get started, please fill out the form and submit to us with these additional documents:

A copy of your insurance license
A copy of your E&O (if you carry it)
A copy of a voided check for direct deposit
A copy of the proof of anti-money laundering training
A copy of the written explaination(s) for any background issues (explained further on the Background Information page)
A copy of your CE training certificate (if required in your state)
If applying as the principal of a corporation: provide a corporate license and a voided check in addition to your individual license
If applying for Athene and are a corporation: provide a corporate resolution or a list of authorized signers

Please be advised that some carriers charge resident and-or non-resident appointment fees. Contact Pinnacle Financial Services for details.

Registration on www.pfsinsurance.com is required to process contracts.

File Upload *

Click or drag files to this area to upload. You can upload up to 10 files.

Initials *

Clear Signature

Date *

Contract Application

Agent Name *

First

Last

Agent Social Security Number *

Agency Name

If applicable

Tax ID

Hierarchy- Agency Affiliation

Personal Name or Principal

Insurance License Number *

Birth Date *

NPN Number *

Agent Gender *

Male
Female

Agent Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Agent Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Residential Phone

Business Phone *

Fax

Mobile *

Email Address *

Previous Address in the Last 10 Years

Address Line 1

Address Line 2

City

State

Zip Code

By signing this form, I acknowledge that all information is true and correct to the best of my knowledge. I agree to receive all carrier required emails, and Pinnacle Financial Services Compliance updates. *

Additionally, by checking here, I agree to let Pinnacle Financial Services send me carriers, products, and lead opportunities.

Preferred Method of Contact *

Email
Phone (Call)
Text

Can select multiple options

Initials *

Clear Signature

Date *

Background Information

All "Yes" answers must have an explanation to be processed.

Is there any indebtedness to any insurance agency? *

Please provide the name of the company, amount, and the repayment agreement: *

All "Yes" answers must have an explanation in order to be processed.

Have you ever been convicted of a felony or misdemeanor other than a traffic offense? *

Please explain and provide the date(s) of each: *

All "Yes" answers must have an explanation in order to be processed.

Have you ever had your driver's license revoked? *

Please explain and provide date(s): *

All "Yes" answers must have an explanation in order to be processed.

Are you in the process of, or have you ever, filed for bankruptcy? *

Please explain and answer the following questions: *

All "Yes" answers must have an explanation in order to be processed.

Have you ever filed bankruptcy, have been declared bankrupt, or insolvent, or have had your salary garnished? *

Have you, or any business of which you were presently are a principal of, been involved in a bankruptcy action, or compromised liabilities with creditors? *

Have you ever filed a petition for bankruptcy or for protection from creditors? *

Has any insurance or securities brokerage firm, with whom you have been associated, ever filed a bankruptcy petition, or been declared bankrupt (either during your association or within 5 years after termination of such association)? *

When was bankruptcy filed? *

What was the amount of the bankruptcy? *

Please select which you filed: *

Chapter 7
Chapter 11
Chapter 13

Please provide the date you filed for bankruptcy: *

Please provide the date your bankruptcy was paid off: *

If applicable.

Are you now, or have you ever been, employed by, or associated with to any degree, directly or indirectly, a bank, savings and loan, or other financial institution? *

Are you now subject of any complaint, investigation, or proceeding which could result in a yes answer to any of the preceeding questions? *

Have you ever been refused a bond or Errors of Omissions Insurance? *

Please explain: *

All "Yes" answers must have an explanation in order to be processed.

Have you ever had your insurance license suspended or revoked? *

Please explain: *

All "Yes" answers must have an explanation in order to be processed.

Have you ever had disciplinary action taken against you with any Department of Insurance? *

Please explain: *

All "Yes" answers must have an explanation in order to be processed.

Are you, or at this present time, or have you been within the past five years, involved in any civil litigation, judgments liens, or foreclosures? *

Please explain: *

All "Yes" answers must have an explanation in order to be processed.

Have you ever been denied an appointment with any insurance company? *

Please explain: *

All "Yes" answers must have an explanation in order to be processed.

Have you ever been terminated for cause by any insurance company? *

Please explain: *

All "Yes" answers must have an explanation in order to be processed.

Initials *

Clear Signature

Date *

Banking Information

Be sure to attach a voided check

Bank Routing Number *

9 digits

Account Number *

Bank Branch Name or Location *

Other Information

Requesting Commission Advancing? *

List a Beneficiary

Relationship

Resident Driver's License State: *

Driver's License Number *

Where were you born? *

(City, State)

Long-Term Care Partnership Certification

Click or drag files to this area to upload. You can upload up to 10 files.

Please attach certificate or CE Update

I confirm that all information is true and correct, and I have given Pinnacle Financial Services my permission to enter the information on my behalf.

Initials *

Clear Signature

Date *

Additional Information (SelectHealth)

If not selecting SelectHealth as a carrier, please disregard this page.

Professional Information

Nevada Accident and Health Insurance License Number

Issue Date

Expiration Date

Please list the names of the carriers with which you are currently appointed, or are applying for appointment.

Have you ever been cited, fined, suspended, revoked, and-or refused a license by any state?

State *

Date *

Have you previously been appointed with SelectHealth?

Please list any languages, other than English, that you speak fluently.

Professional References

Please list any professional associations to which you belong:

Name of Organization

Member Since

Name of Organization

Member Since

Please list two professional references that can attest to your honesty, professionalism, and ethical standards of practice:

Name

Phone Number

Name

Phone Number

Disciplinary Actions

Have you ever been excluded from participating in a government healthcare program such as Medicaid or Medicare? *

If yes, please provide complete background and detail of circumstances *

Please pay particular attention to activities affecting interstate commerce.

File Upload

Click or drag a file to this area to upload.

If needed, you may attach another page.

By signing this form, I acknowledge that all information is true and correct to the best of my knowledge.

Initials *

Clear Signature

Date *

Letter of Explanation

Date of Action

Action

Reason

Explanation

Date of Action

Action

Reason

Explanation

Date of Action

Action

Reason

Explanation

Upload additional documents if necessary

Click or drag a file to this area to upload.

Licenses

AML Provider *

Limra
None
Other

Date Completed *

Are you a registered representative with FINRA? *

Broker/ Dealer Name *

CRD # *

Initials *

Clear Signature

Date *

Agent Referral Information

Agent Name

Phone

Relationship

Agent Name

Phone

Relationship

Agent Name

Phone

Relationship

Agent Name

Phone

Relationship

Agent Name

Phone

Relationship

You Can Earn Extra Money

Call your sales director for more details on our referral program!

65 W Street Rd, Suite A-101 | Warminster, PA 18974
1 (800) 772-6881 | 267-386-8136
www.pfsinsurance.com

Initials *

Clear Signature

Date *

Submit a copy of your E&O Insurance Certificate of Coverage

IMPORTANT: E&O Certificate must list your full name as the insured. Please use the following examples as references.

CORRECT:

Name of Insurance Agency
Full Agent Name
Address Line 1
Address Line 2
City, State ZIP

INCORRECT:

Name of Insurance Agency
Address Line 1
Address Line2
City, State ZIP

If an individual's name is not listed correctly, please provide a letter from the E&O Carrier listing the agents covered under agency policy.

File Upload *

Click or drag files to this area to upload. You can upload up to 10 files.

Carrier Selection

Check the box next to the Carrier names that you would like to select. For non-resident state requests, please write so in the space provided along with the carrier. Please be advised that some carriers charge resident and-or non-resident appointment fees. If you are requesting non-resident appointments, please indicate what states in the block provided.

Checkboxes *

Aetna Medicare Advantage/ Coventry LINK
Aetna Medicare Supplement (ACI/ CLI)
AGLA Life with Living Benefits
Alignment Health LINK
American Equity
American General Life Brokerage Annuity
Americo
Americo Legacy
Anthem BCBS/ Empire/ Amerigroup/ Caremore LINK
Assurity Legacy
Athene Annuity & Life Assurance Company
Athene, IA Annuity
Baltimore Life
Banker’s Fidelity Life/ Assurance Company
BayCare LINK
Blue Cross Blue Shield MI LINK
Bright ACA LINK
Brighthouse Financial
Capitol Life - Med Supp LINK
Cigna ACA LINK
Cigna Final Expense/ Med Sup (Arlic/ Loyal American/ CHLIC)
Cigna HealthSpring (Bravo Health) LINK
Clover Health LINK
Columbian Mutual Life Insurance Company
Combined Insurance Company of America
Devoted LINK
Emblem/ Connecticare LINK
Equitable Annuity
Equitrust
F&G
F&G (Legacy)
Foresters Financial
Foresters Life
Freedom/ Optimum LINK
Global Atlantic
Great American
Great Western GI Life
Guarantee Trust Life
HealthFirst LINK
Humana LINK
Independence Blue Cross
John Hancock
Lincoln Financial
LUMICO MS LINK
Medico Group
Molina ACA LINK
Molina MA LINK
Mutual of Omaha Med Supp/ PDP
Mutual of Omaha Insurance Company (Omaha Insurance, United of Omaha Life Ins., United World Life Ins.)
National Care Dental LINK
National Guardian Life
National Guardian Life Med Supp LINK
National Life Group LINK
National Western
Nationwide
North American Company (NACOLAH) Life & Annuity
Oceanview
Oscar Health LINK
Protective Life
Prudential
Regence
Royal Neighbors of America
SCAN
SelectHealth LINK
Sentinel Security Life Insurance Company
Simply LINK
Sons of Norway LINK
The Standard
Transamerica New York
Transamerica Premier
United Home Life LINK
United Security Assurance
UnitedHealthcare LINK
USIC MS LINK
Washington National
WellCare LINK
William Penn
Other

Non-Res States

Initials *

Clear Signature

Date *