TPA Logo American Benefit Life Insurance Company

Agent

Onboarding

BUSINESS PRACTICES QUESTIONS

1.

Have you ever had an insurance or securities license denied, suspended, cancelled or revoked?

Individual/Officer
Entity

2.

Has any regulatory body ever sanctioned, censured, penalized or otherwise disciplined you?

Individual/Officer
Entity

3.

Has any state, federal or self-regulatory agency filed a complaint against you, fined, sanctioned, censured, penalized or otherwise disciplined you for a violation of their regulations or state or federal statutes?

Individual/Officer
Entity

4.

Have you ever been convicted or plead guilty or nolo contendere (no contest), 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 are any charges currently pending against you for any FELONY offense?

Individual/Officer
Entity

If you answered yes to question 4, please provide the following in the space given below or include a separate page with this application:

For Individual/Officer:
For Entity:

5.

Are you in possession of a valid 1033 waiver from a state DOI or other regulatory authority for any of the above offenses? Please attach/include 1033 waiver if you answered yes.

Individual/Officer
Entity

6.

In the last seven years, have you been convicted or plead guilty or nolo contendere (no contest), 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 are any charges currently pending against you for any MISDEMEANOR offense other than a minor traffic violation?

Individual/Officer
Entity

8.

Are there any unsatisfied judgments, garnishments or liens against you?

Individual/Officer
Entity

7.

In the past ten years, have you personally filed a bankruptcy petition or declared bankruptcy?

Individual/Officer
Entity

9.

Are you in debt to any insurance company?

Individual/Officer
Entity

10.

Are you currently a party to any litigation or a subject of any investigation(s)?

Individual/Officer
Entity

11.

Have you ever had an appointment with another insurance company denied or terminated for cause?

Individual/Officer
Entity

Please provide a detailed explanation in the space below. We will contact you for additional details if needed and your appointment request may be delayed



Do you want to request for Electronic Fund Transfer

If EFT information is not provided will default compensation to check payment

  • Prospect Agent's personal bank information should be provided.
  • If LOA, no bank information is needed.


Disclosure of Intent to Obtain Consumer Reports


This is to advise you that American Benefit Life Insurance Company may obtain one or more consumer reports with respect to establishing your eligibility for employment, appointment, promotion, reassignment, and/or retention as an employee, agent and/or representative of ABL, or one or more of its affiliates.

If requested, the report may be obtained from the investigative consumer-reporting agency named below or another investigative consumer-reporting agency:

Applicant Insight, Inc.
5652 Meadowlane Street
New Port Richey, FL, 34652
www.applicationinsight.com
800 771.7703

If a consumer report is obtained and you reside in a state with a legal requirement to provide a free copy of the consumer report upon request, we will automatically instruct the consumer reporting agency to send you a copy of the report at no charge.


The report may contain information regarding your character, general reputation, personal characteristics and mode of living. The nature and scope of the report is: financial and credit history, criminal records search, licensing and disciplinary action history, and employment history verification.


Notice Regarding Credit Freezes: ABL may require an inquiry into your personal credit history as part of the screening process. If you have exercised your right to freeze your credit profile/report with any of the 3 credit bureaus, ABL asks that you please contact the applicable bureaus to temporarily remove the freeze for a period of no less than 10 days from the date of the application. Failure to remove the freeze may delay, or ultimately eliminate you from, the onboarding process.


For California, Minnesota and Oklahoma applicants only: I request to receive a copy of this report.


At the end of the submission process, you will have the ability to print the 'Disclosure of Intent to Obtain Consumer Reports' for your record.


For California Resident Agents Only

Pursuant to the California Investigative Consumer Reporting Agencies Act, ABL is required to provide you with the summary of provisions listed below.

California Investigative Consumer Reporting Agencies Act Summary of the Provisions of Section 1786.22

(a) An investigative consumer reporting agency shall supply files and information required under Section 1786.10 during normal business hours and on reasonable notice.

(b) Files maintained on a consumer shall be made available for the consumer's visual inspection, as follows:

  • In person, if he appears in person and furnishes proper identification. A copy of his file shall also be available to the consumer for a fee not to exceed the actual costs of duplication services provided.
  • By certified mail, if he makes a written request, with proper identification, for copies to be sent to a specified addressee. Investigative consumer reporting agencies complying with requests for certified mailings under this section shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the investigative consumer reporting agencies.
  • A summary of all information contained in files on a consumer and required to be provided by Section 1786.10 shall be provided by telephone, if the consumer has made a written request, with proper identification for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to the consumer.

(c) The term "proper identification" as used in subdivision (b) shall mean that information generally deemed sufficient to identify a person. Such information includes documents such as a valid driver's license, social security account number, military identification card, and credit cards.Only if the consumer is unable to reasonably identify himself with the information described above, may an investigative consumer-reporting agency require additional information concerning the consumer's employment and personal or family history in order to verify his identity.


(d) The investigative consumer reporting agency shall provide trained personnel to explain to the consumer any information furnished him pursuant to Section 1786.10.


(e) The investigative consumer reporting agency shall provide a written explanation of any coded information contained in files maintained on a consumer. This written explanation shall be distributed whenever a file is provided to a consumer for visual inspection as required under Section 1786.22.


(f) The consumer shall be permitted to be accompanied by one other person of his choosing, who shall furnish reasonable identification. An investigative consumer reporting agency may require the consumer to furnish a written statement granting permission to the consumer reporting agency to discuss the consumer's file in such person?s presence.

Back Continue Save for Later

REFERENCE NUMBER

559093E78C
If completing for an officer and entity, indicate details for 'Yes' answers for each as appropriate.
Please provide a detailed explanation in the space below. If the answers to all questions in 'No', please proceed to next section.