SIM Contracting

Full Legal Name:*
Birth Date:*
Alias/Other Names:
Email Address*
Drivers License #:*
Appointment Type: (Must match info on W-9)*

This must match information provided on W-9. 

Upload a Signature Authorization Form:
Requested Carrier(s) for Contract:
Requested Advancing:*

Requested advancement is not guaranteed and is dependent on background and relationship to broker. 

Phone Number:*
Fax Number:
Social Security #:*
Corporation Name:
Corporate Tax ID:
Business Address:
Mailing Preference: *
Upload Insurance License
Upload Drivers License
Upload E&O Certificate
Upload Voided Check
Business Phone:

Criminal Background Information

1. Have you ever been convicted of a felony?:
2. Have you ever been convicted of a misdemeanor (other than traffic) including an alcohol or drug-related offense?*
3. Have you had your driver's license revoked within the past three years?*

Department of Insurance and CMS

4. Have you ever had your insurance or securities license revoked and/or suspended by any department of insurance (even if later reinstated) for any reason?*
5. Have you ever had a complaint reported against you (even if dismissed) by a consumer and/or insurance company for any reason with any department of insurance, FINRA, or other regulatory reporting agency including CMS?*
6. Have you ever paid a fine related to a consumer complaint, failure to renew your license or continuing education credit in excess of $500?*
7. Have you ever been excluded, or are you aware of actions that could result in an exclusion, by the Office of Inspector General from participation in a government health care program, including Medicare and Medicaid?*

Credit History

8. Have you filed for bankruptcy and/or had a bankruptcy discharged within the last five years?*
9. Are you, at the present time, or have you been within the past five years, involved in any civil litigation, judgements, liens orforeclosures?*
10. Are you, at the present time, or have you been within the past five years, reported as delinquent on state or federal taxes?*

Other Companies

11. Do you owe any insurance company, marketing organization or individual for any premiums collected or monies advanced?*
12. Have you ever been denied an appointment with any insurance company?*
13. Have you ever been terminated for cause by any insurance carrier?*
14. Have you been denied a bond or application for errors and omissions (E&O) coverage with any company?*


15. Do you have other information related to criminal, insurance-related complaints, credit, etc., that was not covered by these questions that you wish to disclose?*

Please provide an explanation for any "Yes" answers on the previous page in the corresponding sections below.

Criminal Background Information:
Department of Insurance and CMS:
Credit History:
Other Companies:
Word Verification:
Fax: 402-434-7764
Mon - Th 8AM - 5:30PM CST
Fri 8AM - 3PM CST
5931 S. 58th Street, Ste A
Lincoln, NE 68516