Life Insurance - Application to send Referrals

Get access to a growing panel of top-rated digital carriers and partners.


Let's get started with your contact information

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

Nice! Please answer the following security questions

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Have your licenses ever been revoked in the past?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?*

Great! We'll get you set up with:

     Haven Life - Life Insurance Referrals

Uh, oh! it looks like your agency is not eligible to send referrals to Haven Life.

We are constantly growing our panel of digital carriers and partners. We will let you know when we get a match for you!

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 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:

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

Address*
9 numbers, no hyphen

Signature

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Agency Officer Name*
Date*
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