Lifebrokers New Agent Profile
It’s easy to become appointed with LifeBrokers. Simply complete the Agent Profile in this section and hit submit. Then fax your state(s) licensing certificate and your E & O certificate to the attention of Marketing at 1-602-494-0500. Your information will be entered into our database and you will be ready to write business with us. When we receive your first application we will send you carrier contracting information. You will receive a contract number for each carrier you write business with. All commissions are paid directly to you from the carrier.

First Name
Last Name
Prefer to be called
Designations
CLU LUTC
ChFC CPCU
CFP RHU
CEP Other
Firm Name, If Any
Is Firm Licensed?
Yes No
Date Business Started
Primary Carrier Today
Refered By

AML (Anti-Money Laundering) Training: Completed
through LIMRA?
Yes Date
If training needs to be completed go to: AML.LIMRA.com. If different provider, email us a copy of the certificate of completion.
Errors & Omissions (E&O) Insurance Carrier
Please provide a copy with this profile

Your Office Address
City
State
Zip Code
Business Phone
Cell Phone
Fax Number
E-Mail Address
Date of Birth
Social Security Number

Your Home Address
City
State
Zip Code

Your MAILING Address
City
State
Zip Code


Comission
You Or To
Tax ID #

If I indicated above that I am insured for errors and omissions insurance, then I agree to immediately notify, in writing, LifeBrokers, Inc., at PO Box 30187, Phoenix, AZ 85046-0187 should the insurance coverage be Terminated or not renewed.

I hereby agree to indemnify and hold harmless LifeBrokers Inc. its employees, from any and all expense costs, causes of action and damages, including attorney’s fees, resulting from or growing out of unauthorized acts or transactions by either myself or persons employed or contracted with me and my organization.

Signed
Date

Send us the form

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