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Individual Form

All documentation requested in the following questionnaire must be received by Kennedy before final processing of your application and submission to the state(s). This includes such things as license copies as specified, copies of any applicable regulatory sanctions, court or arrest records and all other explanations to any "Yes" answers to the questions. Omitting or withholding of this information is often cause for license suspension, revocation or even criminal prosecution.

General:

Address:

34) US Citizen:
36) Gender:
41) Are you a member or veteran of the armed forces, or the spouse or surviving spouse of a service member or veteran?
42) Are you legally blind?

Previous Residence Addresses for last 5 years

Education:

High School:

College:

Employment history for past 5 years (start with present employer, send separate sheet if necessary):

Insurance Industry Background and Training:

History and Qualification Information:

102) Has your name ever been legally changed?
103) Will you devote all of your time to the insurance business?
104) Are you applying for a license primarily for the purpose of procuring insurance for yourself or members of your family?
106) Have you ever had an insurance license denied, suspended, revoked, restricted, canceled, terminated, censured, placed on probation and/or have any regulatory complaints ever been made against you?
107) Have you ever had an insurance license denied, suspended, revoked, restricted, canceled, terminated, censured, placed on probation and/or have any regulatory complaints ever been made against you?

If yes, send complete explanation.  Terminations due to failure to pay renewal fees or noncompliance with continuing education can be excluded.

108) Have you or any firm that you are or have been connected with ever been fined by any state or government agency or authority? If yes explain in full on separate sheet
109) Have you or any firm that you are or have been connected with ever been indebted, for other than current accounts, to any company or person for unpaid premiums or return premiums? If yes, explain in full on separate sheet.
110) Have you or any firm that you are or have been connected with ever been indicted, convicted, enjoined or restrained by a court or regulatory agency for violation of any Federal or State law relating to insurance or securities? If yes, explain in full on separate sheet.
111) Have you ever had an agency contract canceled or any other business relationship with an insurance company terminated for any alleged misconduct or for any other reason? If yes, send complete details (dates, companies, reason canceled).
112) Have you been refused issuance of a Surety or Fidelity Bond, had a bond canceled for cause, or has a surety ever paid a claim on your behalf? If yes send details.
113) Do you have pending or have you ever been arrested, convicted, taken into custody, held for investigation or questioning or charged by any legal authority, pled guilty or nolo contendere to, had adjudication deferred, been on probation for, or are you now under indictment for a felony or misdemeanor offenses? If yes, explain in full on separate sheet.
114) Have you or any firm that you are or have been connected with ever had any professional license (other than insurance) held or applied for by you been revoked, suspended, refused, or the renewal thereof denied by a regulatory body of any state, district or territory? If yes, explain in full on separate sheet.
115) Have you ever held ownership interest in any insurance agency or company? If yes, explain in full on separate sheet.
116) Are you an officer or employee of a financial institution or a subsidiary of such? If yes, explain in full on separate sheet.
117) Are you an officer or employee of, or affiliated with, a public utility? If yes, explain in full on separate sheet.
118) Have you , or any firm of which you have been a member, compromised liabilities with creditors, been insolvent, sued or adjudged bankrupt? If yes, explain in full on separate sheet.
119) Will applicant keep all premium monies separate from other funds? If yes, list name of financial institution, complete addresses and fiduciary account number.
119 b) If no, will immediate remittance of collections be made to insurers?
119 c) If no, will firm have written consent from each and every insurer with which it places business to mingle insurance funds with other funds?
120) Have you ever been notified of any delinquent tax obligation that is not subject to a repayment agreement by any jurisdiction to which you are applying?
121) Have you ever been found liable in any arbitration proceedings or lawsuit(s) involving allegations of conversion or misappropriation of funds, misrepresentation, breach of fiduciary duty or fraud?
122) Do you have a child support obligation in arrearage? If yes, how many months are you in arrearage?
123) Are you the subject of a child support related warrant or subpoena? If yes, explain in full on separate sheet.
124) Are you currently selling insurance over the internet? If yes, identify the following:
125) Are you a trustee, manager, director, officer or otherwise in charge, in whole or in part, of any property or interests of others who carry insurance? If yes, explain in full on separate sheet.

Questions for Variable Contracts Applicants Only:

126) Have you ever qualified for registration with the N.A.S.D.?
127) Have you taken and passed the N.A.S.D. Series 63 Examination?

If yes, what was the date? send a copy of your certificate. 

130) Do you now hold a Resident Securities Salesman's License?
131) Do you now hold a Resident Life Insurance License?

Current Resident Licenses (please send copies):

State licenses being applied for:

175) Call with new quote?
176) Are there any state(s) selected on your initial application to us which need to be added or deleted?

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