Background Questionnaire
1. First Name:		2. Middle Initial:
3. Last Name:		4. Suffix:
5. (If corporate contract, give corporate name and your title)
6. SSN:		15. Company Tax ID#
7. Residence Address:		16. Business Address:
8. City:		17. City
9. State:		18. State:
10. Zip:		19. Zip:
11. Telephone:		20. Telephone:
12. Birth Date:		21. Fax Number:
13. Spouse Name:		22. Cell Number:
14. Email Address:
License/Designations
States which you plan to solicit (Submit a copy of a current license for each state indicated below)
23. Resident License#:		24. State:
25. List all states in which you plan to solicit:
26. Designations & industry awards you currently have:
27. What carrier(s) would you like to get appointed with initially?:
Business/Personal Experience
Yes No	28. Has any insurance company or securities broker-dealer ever terminated your contract other than for lack of production?
Yes No	29. Do you have E & O coverage?
Yes No	30. Have you ever had a claim filed against your E & O insurance coverage?
Yes No	31. Have you ever been bankrupt or insolvent, either personally or in business?
Yes No	32. Have you ever had any liens or judgments, either personally or in business?
Yes No	33. Have you ever been investigated by any state insurance department or government agency?
Yes No	34. Have you ever had an insurance license denied or revoked by a state or province?
Yes No	35: Has a bonding company denied, paid out on, or revoked a bond for you?
Yes No	36: Have you ever been convicted or plead guilty or no contest to a crime other than a misdemeanor?
Yes No	37. Have you ever been on probation?
Yes No	38. Are you now the subject of any complaint, investigation or proceeding that could result in a “Yes” answer to any of the above questions?
39. If any answer is “Yes” to above questions, please provide complete explanation.
Most insurance carriers will not accept appointment forms in advance of your first application. This profile will help us complete the carrier appointment forms as needed. We will always forward the completed form to you for any additional questions the carrier may require as well as your signature. Please be sure to fax your state license(s) along with your E & O insurance coverage. Our fax # is (303) 832-6417. Click submit to send your profile to Rocky Mountain Insurance Network. Thanks for taking the time to provide us with your information. Any questions, call us at (800) 846-3997.