Agent Appointment – OCi Services

OCI Licensing Information Form

Application For*

Agent
Agency

Full Name*

First M.I. Last

Preferred Name

Social Security Number*

Date of Birth:*

Tax ID for Agency*

Agency Name or Agency Affiliate (if applicable)

Phone*

Business Address*

Street Address Address Line 2 City State ZIP Code

Email*

Enter Email Confirm Email

License Information

National Producer Number*

Copy of License(s)*

Drop files here or

Do you have a copy of your own E&O coverage?*

Yes
No

Copy of E&O*

Commission Information

In order for commission to be paid the following EFT information must be completed. Commissions are deposited every Friday for balances over $50.

Will your commissions be paid to your agency?*

Yes
No

Are you the principal of the agency?*

Yes
No

Payee Name*

Bank Name*

Bank Address*

City State

Routing Number*

Account Number*

Copy of voided check*

Completed W-9*

View Blank W-9

Please indicate market segments:*

Individual Medical
Group Medical
Medicare
Ancillary
Worksite (group ancillary)
Individual Life
Disability
LTC
Annuities

Have you completed your LTC/LTC Partnership?

Yes
No

Please upload your LTC/LTC Partnership certificate here:

If you have not completed the LTC/LTC Partnership, please visit http://www.adbanker.com/oci and follow the instructions on the page.

After you complete, please submit certificate to licensing@ociservices.com

Have you completed your Annuity Suitability Training?

Yes
No

Please upload your Annuity Suitability Training certificate here:

If you have not completed the Annuity Suitability Training, please visit http://www.adbanker.com/oci and follow the instructions on the page.

After you complete, please submit certificate to licensing@ociservices.com

How did you hear about us?*

Protecting your private information is important to OCI Insurance & Financial Services, Inc (“OCI”) and our employees. We want you to understand what information we collect and how we use it. In order to provide our customers with a broad range of products and services as effectively and conveniently as possible, we use technology to manage and maintain customer information. The following policy serves as a standard for all OCI employees for collection, use, retention, and security of nonpublic personal information.

View OCI Privacy Policy

I certify that I have downloaded and read the above privacy statement.*

I Agree

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