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Salus Insurance Advisors

Independent Broker Pre-Qualification Form

CONTACT INFORMATION

Full Name *

Email *

Phone *

City *

State *

Country *

Country

Postal Code *

Gender *

LICENSING STATUS

Do you currently hold an active insurance license?

License State *

Lines of Authority (Select all that apply) *

Life

Health

Property & Casualty

Medicare

Annuities

Is your license in good standing with your State Department of Insurance? *

Are Willing To Obtain An Insurance License. *

I am willing to obtain an insurance license within 60 days

I am NOT willing to obtain a license.

Which license are you interested in pursuing? *

Life

Health

Property & Casualty

Not Sure Yet

COMPLIANCE SCREENING

Have you ever been convicted of a felony or financial crime? *

Are you currently under investigation by any insurance carrier or regulatory authority? *

Do you carry active Errors & Omissions (E&O) insurance? *

Yes

No (Required prior to contracting if licensed)

PROFESSIONAL CAPACITY

Years of Experience (if licensed) *

Primary Focus or Intended Focus *

How many client appointments per week can you realistically run? *

STRUCTURE AGREEMENT

Are you willing to operate as a 1099 Independent Contractor? *

Are you willing to follow Salus compliance standards and CRM systems? *

I certify the information provided is accurate.

Contact Us

[email protected]

(866) 846-1270

South Carolina, USA

Salus Insurance Advisors

CONTACT INFORMATION

LICENSING STATUS

COMPLIANCE SCREENING

PROFESSIONAL CAPACITY

STRUCTURE AGREEMENT

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