If I am accepted as an independent contractor for Lashley & Associates
my commissions should be made payable to:
Me, personally
My company
Company Name:
Company Tax ID#:
Licensed for: (please select all that apply)
Life
Series 24
Health
Series 63
Individual
Series 26
Agency
Series 65
Series 6
Series 66
Series 7
Life & Annuity
Other Designation:
Resident State:
Resident License Number:
Primary Markets: (please select all that apply)
Estate Planning
Disability Income
Equities
Long-Term Care
Managed Money
Business Planning
Annuities
CPA
Life Insurance
P & C
Qualified Plans
403B
Fast Facts Questionnaire
Please answer accurately and honestly:
1.
Have you ever been convicted of or plead guilty or no contest to:
A felony?
A misdemeanor?
A violation of federal or state securities
or investment-related regulations?
2.
Are you currently under investigation by any legal
regulatory authority?
3.
Do you now owe any money to any life or
health insurance company?
4.
Have you or a firm in which you were a
partner been declared bankrupt or have you had a salary garnished
or had liens or judgments against you?
5.
Has a bonding company ever denied, paid
out on or revoked a bond for you?
6.
Have you ever been the subject of a consumer-initiated complaint or proceeding by any self-regulated body or any securities commodities
or insurance regulatory body or organization?
7.
Have you ever had a claim filed against your
professional liability or errors and omissions insurance coverage?
8.
Has any insurance department, government
agency or self-regulated authority ever denied,
suspended, revoked, censured or barred your
license or registration or disciplined you with
fines or by restricting your activities?
9.
Do you have more than $50,000 provable gross
insurance commission over the last twelve months?
10.
If accepted, would Lashley & Associates be your only career path?
11.
If accepted by Lashley & Associates, do you understand that you
are an independent contractor subject to a 10-99?
12.
Do you understand that independent contractors are
required to support their own expenses (phone, travel, etc.)?
13.
Do you possess public speaking & presentation skills?
14.
Are you tenacious in your selling abilities?
15.
Are you focused?
16.
Are you coachable?
17.
Are you a self-starter?
18.
Do you have established written goals?
SALES EXPERIENCE
Attach your Resume in an email to Lashley & Associates if information on resume will
substitute for this section.
Begin with your most recent work/sales experience and list separately.
1.
May we contact your current employer?
If “No”, why not?
2a.
From (MM/YY):
To (MM/YY):
2b.
Company Name:
2c.
Address:
2d.
City:
State:
Zip:
2e.
Contact Person:
2f.
Contact Number:
2g.
Total Annual Income:
2h.
You are leaving/left because:
2i.
Using bullet points describe your sales position, responsibilities
and sales closing background:
3a.
From (MM/YY):
To (MM/YY):
3b.
Company Name:
3c.
Address:
3d.
City:
State:
Zip:
3e.
Contact Person:
3f.
Contact Number:
3g.
Total Annual Income:
3h.
You are leaving/left because:
3i.
Using bullet points describe your sales position, responsibilities
and sales closing background:
4a.
From (MM/YY):
To (MM/YY):
4b.
Company Name:
4c.
Address:
4d.
City:
State:
Zip:
4e.
Contact Person:
4f.
Contact Number:
4g.
Total Annual Income:
4h.
You are leaving/left because:
4i.
Using bullet points describe your sales position, responsibilities
and sales closing background:
BY SUBMITTING THIS APPLICATION, I INDICATE THAT I HAVE READ,
UNDERSTOOD, AND AGREED TO THE FOLLOWING: I understand that if Lashley & Associates accepts my application for an insurance agent, agency or financial planner
position, that I will be an “Independent Contractor” (IC) for Lashley & Associates and NOT an
employee of Lashley & Associates. As an IC, I understand and acknowledge that I do not desire,
nor am I entitled to receive, any employee benefits; including, but not limited to,
unemployment or workers’ compensation. I understand that, as an IC, I have the potential
for profit or loss depending upon my own personal business performance, and hereby
indicate my desire to make a financial investment in my own success; including, but not
limited to, the cost of materials, travel, lodging, and meals.
I swear or affirm the information contained herein as well as information submitted to
Lashley & Associates during this application/interview process is true and accurate. I understand
the information I have provided to Lashley & Associates herein forms the basis of a binding
legal obligation. I understand that any false or misleading information, including any
material omissions, may disqualify me from further consideration and/or be grounds for
immediate termination of my IC Agreement. I hereby authorize the verification of any
and all information I have submitted to Lashley & Associates as part of my application/interview
process through a criminal background investigation and through a credit-reporting agency.
I agree to cooperate in any such background investigation and agree to release and
discharge Lashley & Associates, its officers, agents, and employees from any and all liability,
claims, or damages arising either directly or indirectly from information I have supplied
on this application and any credit or criminal background investigation thereof.
By indicating your full name in the field below, you are signing this document as it
relates to the information in the above two paragraphs:
