Please complete the following information. All information will be kept in strict confidence. Information will be securely sent to Agency Relations at AF Group.
Any "YES" answer to the following questions requires a separate explanation, including dates, locations, basis of charge and legal documentation indicating disposition of case.
I hereby certify that all of the information herein is accurate and complete. I acknowledge and agree that my appointment with, in part, be based on this producer profile form and background information, and any falsification, misrepresentation, or omission of information from this form may result in the withholding or withdrawal of any offer or appointment or the revocation of appointment by the company if discovered.
The Violent Crime Control and Law Enforcement Act of 1994 prohibits anyone who has ever been convicted of a felony involving dishonesty or a breach of trust from participating in the insurance business. Violators are subject to fines and up to 5 years imprisonment. I certify that I am in compliance with the Act.