Producer License & Appointment Questionnaire

Type of appointment requested:

	Individual Producer		Individual & Group Producer		Farm Bureau		Shelter Agent
	Group Producer		Met Life		PS Team		Preferred Producer

Contract is in the name of: Agency Producer

Information:

Agency or Producer Name:

Will commissions be assigned to someone other than the name listed above?

Yes

Agency Name:
(complete only if commissions will be assigned)

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)

Sex:

Male

Female

LA Insurance License Number:

License Is:

Individual

Partnership

Corporate

Has this insurance license ever been revoked or suspended?

Yes

If yes, please explain:

Have you ever been appointed with the Blue Cross and Blue Shield of Louisiana?

Yes

If yes, what was your old producer number?

Number of Producing Agents (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 an appointed producer for Blue Cross and Blue Shield of Louisiana:

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 appointed as a producer.

Have you ever been convicted of insurance fraud or of a felony involving dishonesty or a breach of trust?

Yes

If yes, please give details:

Completion of this form does not constitute an appointment 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 appointed 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 is 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.