Important Note: All documentation requested in the following questionnaire must be received by Kennedy before final processing of your application and submission to the state(s). This includes such things as license copies as specified, copies of any applicable regulatory sanctions, court or arrest records and all other explanations to any "Yes" answers to the questions. Omitting or withholding of this information is often cause for license suspension, revocation or even criminal prosecution.

General
1) SSN (required):
2) First Name: 3)  Middle :
4) Last Name:   5) Jr/Sr/etc.:
6) Nick Name or Alias
7) Maiden:
Address
8) Residence Street:
9) City:
10) State:   11) Zip: 11a) County:
12) Business Name:
12a) Business Street:
13) City:
14) State:  15) Zip:  15a) County:
16) Other Street:
17) City:
18) State:   19) Zip:  20) County:
21) Resident Phone:  22) Resident Fax:   
23) Business Phone:  24) Business Fax:
25) E-mail (required): 26) Driver Lic#:  27) State:
28) Birth Date: (mm/dd/yyyy)
29) Birth City:
30) Birth State:  31) Country:
32) US Citizen: Yes | No (if no send copy of green card or work permit)
33) Race (required on fingerprint card):
34) Gender: Male | Female       35)  Height:   36) Weight:
37) Eye Color:   38) Hair color:
Are you a member or veteran of the armed forces, or the spouse or surviving spouse of a service member or veteran? Yes | No
Are you legally blind? Yes | No
Previous Residence Addresses for last 5 years
39)    Residence Street:
Date from: to mm/yy
40) City:
41) State:     42) Zip:
43) Residence Street:
Date from: to mm/yy
44) City:
45) State:    46) Zip:
47)   Residence Street:
Date from: to mm/yy
48) City:
49) State:     50) Zip:
Education
High School
51) Institution:
52) City:   53) State:    
54) Graduation Date (if any):   55) Attended from:   (mm/dd/yyyy) 56)  to (mm/dd/yyyy)

College
57) Institution:
58) City:    59) State:    
60) Major:
61) Graduation Date (if any): (mm/dd/yyyy)  62) Attended from: (mm/dd/yyyy) 63) to (mm/dd/yyyy)
Employment history for past 5 years (start with present employer, send separate sheet if necessary)

64) From:   (mm/dd/yyyy) To: (mm/dd/yyyy)
65) Employer (complete name):
Street:
66) City:     67) State:
68) Zip:
69) Position/Title :
70) Reason for leaving:

71) From: (mm/dd/yyyy)   To : (mm/dd/yyyy)
72) Employer (complete name):
Street:
73) City:   74) State:
75) Zip:
76) Position/Title :
77) Reason for leaving:

78) From: (mm/dd/yyyy)  To : (mm/dd/yyyy)
79) Employer (complete name):
Street:
80) City: 81) State:
82) Zip:
83) Position/Title:
84) Reason for leaving:
Insurance Industry Background and Training
85) Describe (IN FULL) your total years experience and/or training in the insurance industry (not only your licensed years).
History and Qualification Information
 

86).   Has your name ever been legally changed ?
If yes when and why

Yes No

87).   Will you devote all of your time to the insurance business?
If no, how much time will you devote to the insurance business, and in what other businesses are you engaged? (Give %)
Yes No

88.) Are you applying for a license primarily for the purpose of procuring insurance for yourself or members of your family?

What percentage of business written by you in the past five years has been on your own life or property and on the lives or property of your family?
Yes No

89).   Have you ever had an insurance license denied, suspended, revoked, restricted, canceled, terminated, censured, placed on probation and/or have any regulatory complaints ever been made against you?

If yes, send complete explanation.  Terminations due to failure to pay renewal fees or noncompliance with continuing education can be excluded.
Yes No

90).   Have you or any firm that you are or have been connected with ever been fined by any state or government agency or authority? If yes explain in full on separate sheet
Yes No

91).Have you or any firm that you are or have been connected with ever been indebted, for other than current accounts, to any company or person for unpaid premiums or return premiums? If yes, explain in full on separate sheet.  
Yes No

92).   Have you or any firm that you are or have been connected with ever been indicted, convicted, enjoined or restrained by a court or regulatory agency for violation of any Federal or State law relating to insurance or securities? If yes, explain in full on separate sheet.
Yes No

93).   Have you ever had an agency contract canceled or any other business relationship with an insurance company terminated for any alleged misconduct or for any other reason? If yes, send complete details (dates, companies, reason canceled).  
Yes No

94).   Have you been refused issuance of a Surety or Fidelity Bond, had a bond canceled for cause, or has a surety ever paid a claim on your behalf? If yes send details.
Yes No

95).   Do you have pending or have you ever been arrested, convicted, taken into custody, held for investigation or questioning or charged by any legal authority, pled guilty or nolo contendere to, had adjudication deferred, been on probation for, or are you now under indictment for a felony or misdemeanor offenses? If yes, explain in full on separate sheet.
Yes No

96).   Have you or any firm that you are or have been connected with ever had any professional license (other than insurance) held or applied for by you been revoked, suspended, refused, or the renewal thereof denied by a regulatory body of any state, district or territory? If yes, explain in full on separate sheet.  
Yes No
97).   Have you ever held ownership interest in any insurance agency or company? If yes, explain in full on separate sheet.  
Yes No
98).   Are you an officer or employee of a financial institution or a subsidiary of such? If yes, explain in full on separate sheet.
Yes No
99).   Are you an officer or employee of, or affiliated with, a public utility? If yes, explain in full on separate sheet.
Yes No
100).   Have you , or any firm of which you have been a member, compromised liabilities with creditors, been insolvent, sued or adjudged bankrupt? If yes, explain in full on separate sheet.
Yes No
101).   Will applicant keep all premium monies separate from other funds? If yes, list name of financial institution, complete addresses and fiduciary account number.  
Yes No
a.   If no, will immediate remittance of collections be made to insurers?
Yes No
b.   If no, will firm have written consent from each and every insurer with which it places business to mingle insurance funds with other funds?
Yes No
102).   Have you ever been notified of any delinquent tax obligation that is not subject to a repayment agreement by any jurisdiction to which you are applying?
Yes No
103).Have you ever been found liable in any arbitration proceedings or lawsuit(s) involving allegations of conversion or misappropriation of funds, misrepresentation, breach of fiduciary duty or fraud?
Yes No
104).   Do you have a child support obligation in arrearage? If yes, how many months are you in arrearage?  months
Yes No
105).   Are you the subject of a child support related warrant or subpoena? If yes, explain in full on separate sheet.
Yes No
106).   Are you currently selling insurance over the internet? If yes, identify the following:
name of Website:
Server Location:
Yes No
107).   Are you a trustee, manager, director, officer or otherwise in charge, in whole or in part, of any property or interests of others who carry insurance? If yes, explain in full on separate sheet.  
Yes No
   
 Questions for Variable Contracts Applicants Only  
108).   Have you ever qualified for registration with the N.A.S.D.?
Yes No
109).   Have you taken and passed the N.A.S.D.  Series 63 Examination?
If yes, what was the date? send a copy of your certificate.  
Date: mm/dd/yyyy
Yes No
NASC CRD #  
110).   Do you now hold a Resident Securities Salesman's License?
Yes No
111).   Do you now hold a Resident Life Insurance License?
If yes, what is the name of the life insurance company?
Yes No
112).   State your experience, instruction or training in the variable contracts business:

  
   
Carrier information
We generally obtain initial licenses through the carrier with which you place most of your business.  You can obtain additional appointments at a later date.
 
Primary Property & Casualty Carrier
113) Name of Carrier:
(Actual full name of carrier, Not Group)
114) Address:
115) City:
116) State:    116a) Zip:
117) Contact name: (preferably licensing dept.)
118) Phone:   119) 800:
120) E-mail:   121) Fax:
 
Primary Life, Accident & Health, L&D Carrier

122) Name of Carrier:
(Actual full name of carrier, Not Group)
123) Address:
124) City:
125) State:    126) Zip:
127) Contact name: (preferably licensing dept.)
128) Phone:  129)  800:
130) E-mail:  131)  Fax:

 
Current Resident Licenses (please send copies)
State:   lines: Type:
License number(s)    Initial issue date(s) (mm/dd/yyyy)
Qualify by Exam   Exam date(s): (mm/dd/yyyy)
Expiration date: (mm/dd/yyyy) 
State:   lines: Type:
License number(s)    Initial issue date(s) (mm/dd/yyyy)
Qualify by Exam   Exam date(s): (mm/dd/yyyy)
Expiration date: (mm/dd/yyyy) 
State:   lines: Type:
License number(s)    Initial issue date(s) (mm/dd/yyyy)
Qualify by Exam   Exam date(s): (mm/dd/yyyy)
Expiration date: (mm/dd/yyyy)

State licenses being applied for

State
Line(s)
Type(s)
 

Call with new quote? Yes No

Are there any state(s) selected on your initial application to us which need to be added or deleted?  Add Delete