Appointment 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) ______________________________________________________________
What licenses or designations do you hold (if applicable)? _________________________________
Are you a lawyer or accountant? Y / N Do you work in Senior Living or Long-Term Care? Y / N If Y, list type of care and name of company __________________________________________________
LICENSES INFORMATION: Do you hold one or more life insurance, life settlement brokerage, or securities licenses? Y / N LICENSING INFORMATION (if applicable): Please list all states in which you hold life insurance, life settlement broker, viatical broker or securities broker. (Please attach additional sheets, if necessary)
1. State __________________________ Type of License ________________________ Date Approved ___________________ Expiration Date ________________________ License Number ___________________
2. State __________________________ Type of License ________________________ Date Approved ___________________ Expiration Date ________________________ License Number ___________________
3. State __________________________ Type of License ________________________ Date Approved ___________________ Expiration Date ________________________ License Number ___________________
4. State __________________________ Type of License ________________________ Date Approved ___________________ Expiration Date ________________________ License Number ___________________
5. State __________________________ Type of License ________________________ Date Approved ___________________ Expiration Date ________________________ License Number ___________________
Do you have working relationships with any other life settlement funders or brokers?
Y/N
If yes, please list: ______________________________________________________________________________________
______________________________________________________________________________________
LITIGATION / REGULATORY ACTIONS:
Have you ever had a professional license revoked or suspended? Yes No 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? Yes No If yes, Please explain: ____________________________________________________________________________________
____________________________________________________________________________________
SIGNATURE I hereby certify that the above information is true and accurate to the best of my knowledge and I agree to comply with all state and federal licensing/registration requirements, statutes and regulations that pertain to the sale or solicitation of life settlements. 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