Application Please complete and e-mail this application to info@lcxlife.com
REFERRAL AGENT INFORMATION:
Name ____________________________ Business Name (if applicable)____________________________________ Address _______________________________________________________________ Phone ____________________________
Fax ____________________________
E-Mail ____________________________ Website___________________________ Social Media Handles______________________________________________________
UPLINE BROKERAGE GENERAL AGENCY INFORMATION: BGA NAME (list one or more if applicable): _________________________________________________
BUSINESS INFORMATION: How long have you been in business? _________________________________
What types of services or products do you provide? _______________________________
Please list what types of insurance or financial products you provide (if applicable) ______________________________________________________________
Are you a licensed life settlement broker Y / N
Are you a lawyer or accountant? Y / N
Do you work in Senior Living or Long-Term Care? Y / N
LITIGATION / REGULATORY ACTIONS:
Have you ever had a professional license revoked or suspended? Y / N
If yes, Please explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Have you or anyone in your company ever been refused a license, ever been charged with violating a Federal or State regulation, ever been convicted of, or have pending, any criminal action? Y / N If yes, Please explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Are you currently covered by Errors and Omissions (E&O) insurance for life settlements? Y / N ** LCX Life provides E&O coverage to appointed referral agents for life settlement transactions done via LCX Life’s LifeCare Xchange platform. The liability coverage limit is $5 million and underwritten by Lloyds.
SIGNATURE: I hereby certify that the above information is true and accurate to the best of my knowledge and I further agree to keep LCX Life informed of any changes in status of any licenses or any information presented above.
_______________________________________________________________________________ Please Print Name
_______________________________________________________________________________ Signature and Date
LCX Life: LCX Life is the only Life Settlement Marketing Organization (LSMO) in the insurance industry. Our mission is to work with agents, advisors, and our IMO/BGA partners to build a network of Appointed Referral Agents who are educated and supported to offer the life settlement option to policy owners contemplating lapse or surrender. We also work with independent agents, financial advisors, lawyers, accountants, and long-term care industry service providers. With LCX Life, we can rescue thousands of policies every year, and in the process, deliver a recurring revenue stream to your organization. www.lcxlife.com