Life Insurance - Appointment Application


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Note: Your privacy is very important to us. To better serve you, the form information you enter is recorded in real time.

Name*
Security Questions OK
States Ok
In which states do you have more than 100 customers?*

Nice! Now we will ask you a few security questions

Please select the types of insurance that you are licensed to sell:*
Have you ever been convicted of crime?*
Have you ever filed for bankrupcy?*
Have your licenses ever been revoked in the past? (In your state and any other states for which you may issue or service insurance policies)*
Has any court, regulatory agency or exchange ever entered an order against the Entity related to insurance, investment, banking or fraud? *
Are there any pending litigation or regulatory matters which may have a material impact on the Entity’s ability to conduct business?*
Has a bond application ever been rejected or revoked?*

To be appointed for life insurance, your agency must conduct background checks. If you do not conduct them, you will still be eligible to send life insurance referrals

Is the entity conducting due diligence on its producers and can the entity produce the background investigation documentation upon request?*

Great! We will get you connected with:

     Haven Life - Life Insurance
     Haven Life - Life Insurance (Referrals only)

Uh, oh! it looks like you do not want to send referrals to Haven Life (If you do, just go back and change your last response)

If there is anything else we can help you with, please let us know below:

Uh, oh! it looks like you do not want to be appointed to Haven Life (If you do, just go back and change your last response)

If there is anything else we can help you with, please let us know below:

Uh, oh! it looks like your agency is currently not eligible to send referrals or get an appointment with Haven Life. 

We are constantly growing our carrier of digital carriers and partners. We will let you know when there is one that fits your needs!

If there is anything else we can help you with, please let us know below:

Now it's time to gather information on your W-9, E&O policy and business licenses

9 numbers, no hyphen
No File Chosen
File uploads may not work on some mobile devices.

Agency Errors and Omissions Policy

$
Minimum amount required of $1,000,000 per occurrence or claim made
Expiration Date*
No File Chosen
File uploads may not work on some mobile devices.

Great! You're almost done. Please tell us about your agency

Physical Address*
Mailing Address different from Physical Address?*
Mailing Address*

Please let us know about your agency’s owners and producers

Each Agency Owner and Produer licensed to sell life insurance will get access to Haven Life's agent portal

If you have over five Owners, Corporate Partners or Officers, please send the required information via email to appointments@agentero.com

Name 1*
Name 2*
Name 3*
Name 4*
Name 5*

Additional Agency Producers

Each Producer licensed to sell life insurance will get a login to Haven Life Portal

If you have over 10 additional Agency Producers, please send the required information via email to appointments@agentero.com

Name 1*
Name 2*
Name 3*
Name 4*
Name 5*
Name 6*
Name 7*
Name 8*
Name 9*
Name 10*
No File Chosen
File uploads may not work on some mobile devices.

Please upload .zip files or submit required documents back to appointments@agentero.com

Tip: to create a .zip file insert documents into a folder and right-click > send to > compressed (zipped) folder (Windows) or  control-click > compress (Mac).

Great! You’re almost done. Please tell us about your agency

Physical Address*
9 numbers, no hyphen

Signature

Use your mouse or finger to draw your signature above
Agency Officer Name*
Date*
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