CUL Appointment Kit 2015
APPOINTMENT INSTRUCTIONS CENTRAL UNITED LIFE INSURANCE Please follow the instructions and checklist below to become appointed with CUL under GoHealth. Incomplete submissions will cause a significant delay in processing. Processing takes approximately 10-14 business days. Once the agent submits a contract, they will have 45 days to submit a piece of business. Once the business has been submitted, the agent will receive their agent number. *Please send the completed appointment kit to your GoHealth VMO Manager. Confidential Leasing Information □ □ □
Complete all items thoroughly Complete items 1-8 by indicating “YES” or “NO” If answering “YES” to any of the questions please explain in the comment section Sign and date
Agent Agreement Form □ □ □
Page 6: Insert day, month, year, and name Page 9: Print name, sign, and date Page 9: Guarantee To Be Executed If Agent Is A Corporation should be completed only if you are applying as a corporation
Assignment of Commission for All Company(ies) Above □ □ □ □ □ □
Name is provided as GoHealth, LLC. Do not edit Address is provided as 214 W. Huron Street, Chicago, IL 60654. Do not edit Tax ID # is provided as 263235175. Do not edit. “Executed at” should be provided as applicant’s resident city and state Enter date (This- day of the month, Day of- month, fill in the year Sign, print name, and enter tax ID #.
Representative Agreement □
Complete as follows: o Line 2: Agent Name o Representative: Agent Name o Representative Signature: Agent signature o Date as indicated for both Representative and Associate
Family Life Insurance Company (Complete only if applying for appointment in Michigan or Florida) □ □ □
Page 12: Insert day, month, year, and name Page 15: Insert name, sign, and date Page 15: Guarantee To Be Executed If Agent Is A Corporation should be completed only if you are applying as a corporation
Indicate in Which States You Wish to Become Appointed □ □ □
Indicate all that apply Make check payable to: Central United Life (if not using Credit Card Authorization Form) Mail Checks to: BMC Agency 1529 Sam Rittenberg Blvd. Ste 200 Charleston, SC 29407
CUL/MIG Appointment Fees Credit Card Authorization □ Complete only if you are not paying for fees with a check Note: Checks will take longer to process than credit card payments □ Sign and date General Items to Remember □ □ □ □ □
Attach copy of Driver’s License Attach copy of Resident State Insurance License Attach copy of licenses for all states in which you wish to be appointed Attach copy of current E&O Attach copy your check for appointment fees only if you are not using the credit card option
Complete all items thoroughly Complete items 1-8 by indicating “YES” or “NO” If answering “YES” to any of the questions please explain in the comment section Sign and date
Agent Agreement Form □ □ □
Page 6: Insert day, month, year, and name Page 9: Print name, sign, and date Page 9: Guarantee To Be Executed If Agent Is A Corporation should be completed only if you are applying as a corporation
Assignment of Commission for All Company(ies) Above □ □ □ □ □ □
Name is provided as GoHealth, LLC. Do not edit Address is provided as 214 W. Huron Street, Chicago, IL 60654. Do not edit Tax ID # is provided as 263235175. Do not edit. “Executed at” should be provided as applicant’s resident city and state Enter date (This- day of the month, Day of- month, fill in the year Sign, print name, and enter tax ID #.
Representative Agreement □
Complete as follows: o Line 2: Agent Name o Representative: Agent Name o Representative Signature: Agent signature o Date as indicated for both Representative and Associate
Family Life Insurance Company (Complete only if applying for appointment in Michigan or Florida) □ □ □
Page 12: Insert day, month, year, and name Page 15: Insert name, sign, and date Page 15: Guarantee To Be Executed If Agent Is A Corporation should be completed only if you are applying as a corporation
Indicate in Which States You Wish to Become Appointed □ □ □
Indicate all that apply Make check payable to: Central United Life (if not using Credit Card Authorization Form) Mail Checks to: BMC Agency 1529 Sam Rittenberg Blvd. Ste 200 Charleston, SC 29407
CUL/MIG Appointment Fees Credit Card Authorization □ Complete only if you are not paying for fees with a check Note: Checks will take longer to process than credit card payments □ Sign and date General Items to Remember □ □ □ □ □
Attach copy of Driver’s License Attach copy of Resident State Insurance License Attach copy of licenses for all states in which you wish to be appointed Attach copy of current E&O Attach copy your check for appointment fees only if you are not using the credit card option
