Producer Questionnaire Type of request: New Change to existing contract Type of contract requested: Individual Producer Individual & Group Producer Farm Bureau Shelter Producer       Group Producer Met Life PS Team Preferred Producer Contract is in the name of: Agency Producer Information: Name: If this is a producer contract request, will commissions be assigned to someone other than the name listed above? Yes No If yes, Agency Name: Business Street Address:   (All correspondence will be sent to this address, unless otherwise requested.) City: State: Zip: Business Phone: Home Phone: Cell Phone: Fax: E-Mail: Date of Birth:  (ex. 01/01/2006) Tax ID or Social Security Number: Sex: Male Female Race of business owner or producer: African American Asian Caucasian Hispanic Other LA Insurance License Number: Has this insurance license ever been revoked or suspended? Yes No   If yes, please explain: Have you ever been contracted with Blue Cross and Blue Shield of Louisiana? Yes No   If yes, indicate producer number: Number of active producers (in agency): Property Casualty: Life/Health: Top Three Life and Health Companies Represented: Companies Represented: Annual Written Premium Volume: Years Represented: Specific reasons for wanting to become a contracted producer for Blue Cross and Blue Shield of Louisiana: Name of BCBSLA contact (if applicable): The Federal Insurance Fraud Provisions of the Violent Crime Control Act make it a criminal offense for Blue Cross and Blue Shield of Louisiana to willfully permit any person who has been convicted of insurance fraud or felony involving dishonesty or breach of trust to be employed by Blue Cross and Blue Shield of Louisiana or contracted as a producer. Have you ever been convicted of insurance fraud or of a felony involving dishonesty or a breach of trust? Yes No If yes, please give details: Completion of this form does not constitute a contract as a producer for Blue Cross and Blue Shield of Louisiana. Applicant should be informed that to be/become a Blue Cross and Blue Shield of Louisiana contracted producer to sell individual products, some training may be required.   I certify that all of the above information is correct to the best of my knowledge. I understand that any misrepresentation made on my part may be grounds for termination of my contract and/or appointment(s) with Blue Cross and Blue Shield of Louisiana and its subsidiaries.       Please press the Submit button only once to have this form sent.