Your Onboarding starts here

Onboarding Packet

Pre Requirements

To complete this form, make sure you have these items readily available

Personal information Including Social Security Number, Date of Birth, Current Address
Designation of Commissions: As Earned (Month to Month) or Advanced
Proof of current Errors and Omissions Coverage
Anti-Money Laundering Certificate (If Selling ANY Life Insurance)
Valid Voided Check or EFT form to set up your Bank deposits. (Not required for Licensed Only Agents, LOA)
Supporting documents required for background questions
CMS/FFM Certification is required BEFORE requesting any Affordable Care Act (ACA) Carriers.
AHIP Certification is required BEFORE requesting any Medicare Carriers. (Discount with Aetna provided below)

If Doing Business as an Agency or LLC

Business needs to be licensed and registered with NIPR.
Business EIN and National Producer Number

Agent Information

Date of birth *

Your Gender *

Address (can not be P.O. Box) *

City *

Resident State *

Postal code *

Full Social Security Number *

Drivers License Number *

Drivers License State *

Agent's NIPR Number *

Resident Insurance License Number *

What states are you Licenced in? *

What carriers are you currently contracted with outside of Impact? *

I'm Doing Business: *

Are you a Registered Rep with FINRA? *

Agency NIPR number (if applicable)

Finra CRD#

If you selected Business Entity, provide the following:

EIN Number
Business Entity Name
Business Entity Address
Business Entity Phone
Business Entity Email
Principal's Name
Your Title

Voided Check or Valid EFT Form

Upload Voided Check Here

Upload documents here

If doing business as an Individual or a Business, this is REQUIRED. Failure to submit with a Voided check or EFT form will result in delays in Onboarding and Contracting.

Banking/ Deposit

Please print Deposit Information for Verification

Account Owner Name
Financial Institution Name
Branch Address
City, State, Zip
Phone
Account Number
Transit/ABA Number
Checking or Savings Account:

Bank Authorization

Electronic Funds Transfer Agreement: By Signing below I hereby authorize the Company to initiate credit entries and, if necessary, adjustments for credit entries in error to the checking and/or savings account indicated on this form. This authority is to remain in full effect until the company has received written notification from me of its termination. I understand that this authorization is subject to the terms of any agent or representative contract, commission agreement, or loan agreement that I may have now, or in the future, with the Company. *

Clear

Errors & Omissions

Upload a copy of your E&O Policy Certificate Here

Upload documents here

Anti-Money Laundering

Upload a copy of your Anti-Money Laundering Certificate if selling Life Insurance. If using LIMRA please provide a screenshot from your Limra account that shows the Course Name and Date completed.

Upload documents here (Required if selling Life Insurance)

AHIP Certification

Upload a copy of your AHIP Certification If selling Medicare

CMS/FFM Certification

Upload a copy of your CMS/FFM Certification if selling Under 65/ ACA

Releases

Upload any Releases from Past IMO/FMO

Agent Profile

We need a headshot photo from you. This photo will be used as your professional profile picture for our company website, social media pages, as well as your ID badge and business cards.

For best results

Find a solid, clutter free background
Use natural light (do not use flash)
Have a family member or friend take your photo, no selfies please!
Smile and look into the camera lens

Headshot Photo

Background Information

1. Have you ever been charged or convicted of or plead guilty or no contest to any Felony, Misdemeanor, federal/state insurance and/or securities or investments regulations and statutes? Have you ever been on probation? *

Yes

1A. Have you ever been convicted of or plead guilty or no contest to any Felony?

Yes

If yes, please answer the questions below:

1B. Have you ever been convicted of or plead guilty or no contest to any Misdemeanor?

Yes

1C. Have you ever been convicted of or plead guilty or no contest to a violation of federal or state securities or investment related regulations?

Yes

1D. Have you ever been convicted of or plead guilty or no contest to a violation of state insurance department regulations or statutes?

Yes

1E. Has any foreign government, court, regulatory agency, or exchange ever entered an order against you related to investments or fraud?

Yes

1F. Have you ever been charged with a Felony?

Yes

1G. Have you ever been charged with a Misdemeanor?

Yes

1H. Have you ever been on probation?

Yes

2. Have you ever been or are you currently being investigated, have any pending indictments, lawsuits, or have you ever been in lawsuit with insurance company? *

Yes

If yes, please answer the questions below:

2A. Are you currently under investigation by any legal or regulatory authority?

Yes

2B. Have you been under investigation by any insurance company?

Yes

2C. Have you ever been or are you currently involved in any pending indictments, lawsuits, civil judgments or other legal proceedings (civil or criminal) (you may omit family court)?

Yes

2D. Have you ever been named as a defendant or codefendant in a lawsuit, or have you ever sued or been sued by an insurance company?

Yes

3. Have you ever been alleged to have engaged in any fraud? *

Yes

4. Have you ever been found to have engaged in any fraud? *

Yes

5. Has any insurance or financial services company, or broker-dealer terminated your contract or appointment or permitted you to resign for reason other than lack of sales? *

Yes

If yes, please answer the questions below:

5A. Were you terminated/resigned because you were accused of violating insurance or investment related statutes, regulations, rules or industry standards of conduct?

Yes

5B. Were you terminated/resigned because you were accused of fraud or the wrongful taking of property?

Yes

5C. Failure to supervise in connection with insurance or investment related statues, regulations, rules or industry standards of conduct?

Yes

6. Have you ever had an appointment with any insurance company terminated for cause or been denied an appointment? *

Yes

7. Does any insurer, insured, or other person claim any commission chargeback or other indebtedness from you as a result of any insurance transactions or business? *

Yes

8. Has any lawsuit or claim ever been made against you, your surety company, or errors and omissions insurer arising out of your sales or practices, or, have you been refused surety bonding or E&O coverage? *

Yes

If yes, please answer the questions below:

8A. Has a bonding or surety company ever denied, paid on or revoked a bond for you?

Yes

8B. Has any Errors & Omissions (E&O) carrier ever denied, paid claims on or cancelled your coverage?

Yes

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

Yes

10. Has any state or federal regulatory body found you to have been a cause of an investment OR insurance-related business having its authorization to do business denied, suspended, revoked, or restricted? *

Yes

11. Has any state or federal regulatory agency revoked or suspended your license as an attorney, accountant, or federal contractor? *

Yes

12. Has any state or federal regulatory agency found you to have made a false statement or omission or been dishonest, unfair, or unethical? *

Yes

13. Have you ever had any interruptions in licensing? *

Yes

14. 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? Have you ever been the subject of a consumer initiated complaint? *

Yes

If yes, please answer the questions below:

14A. Has any regulatory body ever sanctioned, censured, penalized or otherwise disciplined you?

Yes

14B. Has any state, federal, or self-regulatory agency filed a complaint against you, fined or sanctioned you?

Yes

14C. Have you ever been the subject of a consumer initiated complaint?

Yes

15. Have you personally or any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or declared bankruptcy? *

Yes

If yes, please answer the questions below:

15A. Have you personally filed a bankruptcy petition or declared bankruptcy?

Yes

15B. Has any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or been declared bankrupt either during your association or within five years after termination of such association?

Yes

15C. Is the bankruptcy pending?

Yes

16. Have you ever had any unsatisfied judgments, garnishments, or liens against you? *

Yes

17. Are you connected in any way with a bank, savings & loan association, or other lending or financial institution? *

Yes

18. Have you ever used any other names or aliases? *

Yes

19. Do you have any unresolved matters pending with the Internal Revenue Service or other taxing authority? *

Yes

Explanation If you answered any questions “yes,” provide an explanation that includes dates, actions and descriptions. Attach additional paper if necessary.

Attach any additional Explanations here

Communication Consent

TCPA Consent.

I consent and approve of receiving calls, SMS messages (including text messages) and emails from Impact Legacy Group, their affiliated companies, or their agents, representatives, or affiliates or anyone calling on their behalf for any and all purposes arising out of or relating to our mutual relationship, at any telephone number, or physical or email or electronic address you provide us or at which you may be reached. Telephone numbers you provide include those you give to us, those from which you or others contact us, or which we obtain through other means. You agree we may contact you in any way, including SMS messages (including text messages) calls using pre-recorded messages or artificial voice, and calls and messages delivered using automatic telephone dialing systems (auto‐dialer) or an automatic texting system. Automated messages may be played when the telephone is answered, whether by you or someone else. In the event that an agent or representative calls, he/ she may also leave a message on your answering machine, voice mail, or send one via text. IMPACT LEGACY GROUP, OUR AGENTS, REPRESENTATIVES, AFFILIATES AND ANYONE CALLING ON OUR BEHALF MAY USE SUCH MEANS OF COMMUNICATION DESCRIBED IN THIS SECTION.

TCPA Consent *

I Agree

Agent Agreement

I attest that the information I have provided is true to the best of my knowledge. I acknowledge that if any information changes, I will notify my agency office within 5 days of such change. Further, I understand that my agency may contact me when I need to answer specific questions. I further understand and agree that this form and the information contained herein will be shared with First Heartland Corporation, its affiliated companies, and any other organization, entity, or person with whom I am seeking licensure, registration, or appointment. *

Clear

Agent Authorization

Signature Authorization. PLEASE READ THIS AUTHORIZATION, SIGN IN THE BOX BELOW AND SUBMIT THIS FORM BY FOLLOWING THE INSTRUCTIONS PROVIDED ON THE COVER PAGE. I hereby authorize SuranceBay, LLC, its general agency customers, and First Heartland® (the “Authorized Parties”) to affix or append a copy of my signature, as set forth below, to any and all required signature fields on forms and agreements of any insurance carrier (a “Carrier”) designated by me through SureLC software or through any other means, including without limitation, by e-mail or orally. The Authorized Parties shall be permitted to complete and submit all such forms and agreements on my behalf for the purpose of becoming authorized to sell Carrier insurance products. I hereby release, indemnify and hold harmless the Authorized Parties against any and all claims, demands, losses, damages, and causes of action, including expenses, costs and reasonable attorney’s fees which they may sustain or incur as a result of carrying out the authority granted hereunder. By my signature below, I certify that the information I have submitted to the Authorized Parties is correct to the best of my knowledge and acknowledge that I have read and reviewed the forms and agreements to which the Authorized Parties have been authorized to affix my signature. I agree to indemnify and hold any third party harmless from and against any and all claims, demands, losses, damages and causes of action, including expenses, costs and reasonable attorney’s fees which such third party may incur as a result of its reliance on any form or agreement bearing my signature pursuant to this authorization. Please sign in the center of the box below. *

Clear

What Happens Next

Once submitted, and Verified, you will receive access to all “Impact Resources” followed by an email with contracting invitations for the carriers/ product affiliated with your agency. - Familiarize yourself with the resources and Look out for your contracting Links.(Check Spam/Junk) Be sure to complete All carrier contracts ASAP

Impact Contracting Team receives all completed contracts, processes and sends them to the carrier for final approval and a writing number. - Connect with our Impact community and continue training

You will receive an email from the individual carrier with Your writing number and login information to their specific carrier portal. - Navigate to carrier portals, Save Login information and begin serving clients

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply.

Your Onboarding starts here

Pre Requirements

Agent Information

Voided Check or Valid EFT Form

Banking/ Deposit

Bank Authorization

Errors & Omissions

Anti-Money Laundering

Agent Profile

Background Information

Communication Consent

Agent Agreement

Agent Authorization

What Happens Next

YOU WERE MADE FOR IMPACT