Appointment Paperwork

Congratulations!! Your decision to move to the next step is among the smartest decisions you've ever made. To maintain the momentum complete the application form below. The more complete your application the better we'll be able to evaluate your qualifications and allow you to continue your journey to a better lifestyle with Assurecor!

 

Note:  Fields with an * are required.  However, a fully completed questionnaire will likely get you evaluated and placed faster.

Contact Information:
* First Name:
* Last Name:
* Address:
* City:
* State:
* Zip Code:
(format XXXXX  -or-  XXXXX-XXXX)
County:
* Daytime Phone:   
Home Phone:   
Cell Phone:   
* At which number do you prefer we contact you during working hours?   
Fax Number:
* E-Mail Address:
* Referral Source:
* Enter "Other" Referral Source:
* Enter Referral Friend's Name:
License Information:
* Do you have your Life & Health Insurance License?   
Note: The following three entries are only required if you answered "Yes" above.
* In what states are you licensed? (Separate with commas)  
* Have you sold health insurance?   
* If so, for what organization?  
*List companies you are appointed with?  (Separate with commas)
* Do you have an office outside your home?   
* How many years in the insurance business?  
  (click here to lookup)

Goals - Where you are and where you want to be:
Approximate Annual Income Last Year?
What was your Highest Annual Income?
At what job did you earn this income?
What is your Income Goal?
What is your work load preference?
Management Skills:
* Do you have management experience?  
Note: The following three entries are only required if you answered "Yes" above.
* How many people have you managed?
* Are you currently managing a group of agents?
* Are you interested in management with us?

Additional Background Information:
Do you have experience with health insurance telemarketing or other direct response leads"?   

Any Additional Comments