COMMISSION SCHEDULES

STATE PRODUCT REFERENCE DOCUMENTS
Connecticut Medical Supplement PDF Name
Connecticut Final Expense PDF Name
New York Medical Supplement PDF Name
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TPA Logo American Benefit Life Insurance Company

Agent

Onboarding

INDIVIDUAL APPLICANT APPOINTMENT INFORMATION

Name : Mr Tommie Howard   SSN :       NPN : 2636161
Gender : M    Date of Birth: 01/17/1970       Primary Phone: 317-519-3369
Secondary Phone:     
Residential Address: 7034 Halifax Ct
   Business Address: 7034 Halifax ct
   Avon     Avon
   IN     IN
   46168     46123
Email : tommie.t.howard@gmail.com    Preferred Mailing Address: Residential      

APPOINTMENT STATES REQUESTED

Requested by initiator :
State Product
IN Medicare Supplement
Resident State : IN      

BUSINESS PRACTICES QUESTIONS

Sl# Question Individual
1 Have you ever had an insurance or securities license denied, suspended, cancelled or revoked? N
2 Has any regulatory body ever sanctioned, censured, penalized or otherwise disciplined you? N
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? N
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? N
Year of offense(s):
Jurisdiction (county or federal district) where the case(s) took place:
Your name at the time of the offense:
Charges/Offences:
Sentencing and other information:
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. N
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? N
7 In the past ten years, have you personally filed a bankruptcy petition or declared bankruptcy? N
8 Are there any unsatisfied judgments, garnishments or liens against you? N
9 Are you in debt to any insurance company? N
10 Are you currently a party to any litigation or a subject of any investigation(s)? N
11 Have you ever had an appointment with another insurance company denied or terminated for cause? N

ELECTRONIC FUNDS TRANSFER (EFT)

Bank Name : HUNTINGTON NATIONAL BANK          Routing Number : 074000078          Account Number : 02401146464

COMMISSION ADVANCE

Commission Advance:
Product Advance Selected By Initiator (month) Advance Selected By You (month)
Medicare Supplement 0 12

ACKNOWLEDGEMENT AND SIGNATURE

Agent Contract :       viewPdf View Agent Contract PDF
Commission Advance Addendum :       viewPdf View Commission Advance Addendum PDF
W-9 Form :       viewPdf View W9 PDF
Producer Information And Appointment Form   :       viewPdf View Completed PIF

  • Acknowledge that you have read, understood and agree to comply with the provisions contained in your agent contract, commission advance addendum, and/or Final expense life insurance commission advance and financing agreement, as applicable, and Producer Compliance Manual and the Business Associates Agreement, all of which may be downloaded and printed at https://www.suppinsadmin.com/ssitpa/tpaSecure/abl/ablHome.html or you may also request a copy by calling .

  • Agree to receive official correspondence including, but not limited to, contracts, contract amendments, commission schedules, bulletins, notices and other Company communications, by email and by posting to the agent web portal at https://www.suppinsadmin.com/ssitpa/tpaSecure/abl/ablHome.html. You further agree to notify the Company if you change your email address by emailing the Licensing Department at AETSSIContracting@aetna.com.

  • Acknowledge that you have received and read the Disclosure of Intent to Obtain Consumer Reports and you consent and authorize ABL and its affiliates to obtain additional background information, as we deem necessary, through independent investigation, FINRA CRD reports, from the National Insurance Producer Registry and/or through an investigative consumer reporting agency (consumer reporting agencies including but not limited to those identified in the 'Disclosure of Intent to Obtain Consumer Reports') and other consumer reports (collectively, "background reports").

  • Authorize us to share with our affiliates the information contained in this PIF or any other information that we may obtain including background reports for the purposes of establishing your eligibility and/or continuing eligibility for appointment with us and our affiliates as well as you authorize us to share any such information as required by law.

  • Authorize your employers and other insurance companies you are or have been appointed with to release to us any and all information that they may have about you, personal or otherwise, and you agree to release all such parties from all liability that may result from furnishing this information to us.

  • Understand and agree that your appointment will, in part, be based upon this PIF and the background report information and that any information you provide us that is inaccurate or incomplete shall be grounds for termination of your appointment.

  • Certify that you have not been convicted of any criminal felony involving dishonesty or breach of trust or been convicted of an offense under section 1033 of the Violent Crime and Law Enforcement Act of 1994. You agree to immediately inform the Company of any arrest of the types described in the preceding sentence.

  • If applicable, authorize ABL or any of its affiliates to automatically transfer funds to your checking account and make adjustments to your account in the event of errors. Additionally, you authorize the named financial institution to complete these transactions. This authorization is to remain in full force and effect until we receive written notice from you requesting termination or until we have notified you of our intention to terminate your EFT services.

  • You acknowledge that you have personally reviewed the information and answers contained in your completed PIF and you certify under penalty of perjury that the information provided herein is accurate and complete.
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REFERENCE NUMBER

559093E78C