Fillable MetLife Appointment Form Only (Dickerson Insurance Services)

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MetLife Appointment Form Only (Dickerson Insurance Services)

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MetLife
1
Appointment Form Only
Steps to obtain an Appointment:
Complete the Personal Information Sheet Entirely
The Personal Information Sheet is used to obtain information necessary to establish an appointment with MetLife. Page 2,
the Application Form must be completed in it’s entirety as applicable. If you are requesting an appointment for only the
Agent, than only the Agent fields need to be completed. If the request for appointment includes the Agency, all fields need
to be completed.
Page 4 must be executed by appropriate parties.
Page 5 must be executed by the appointment applicant.
The applicant must be licensed in the s
tate you are requesting your appointment for.
When do you request an appointment?
For the states listed below (pre-appointment) a producer must be licensed and appointed with MetLife prior to the customer
application being executed.
Pre-Appointment States:
Florida Montana
Georgia North Carolina
Indiana Oregon
Kansas Pennsylvania
Louisiana Puerto Rico
Missouri Utah
For all other states, the appointment request must be made no later than MetLife’s receipt of the customer application.
Mail or Fax: Service Delivery Center
Attn: Corporate Licensing &Registration
Schoolhouse50 0 Road
Johnstown, PA 15904
This form cannot act as an authorization to assign commissions.
ID - INST BUS PAI (10/08)
Mail: Service Delivery Center
Attn: Corporate Licensing & Registration
500 Schoolhouse Road
Johnstown, PA 15904
Fax: 908-552-2444
email: CLR_Institutional@metlife.com
Please check the appropriate coverage(s) you are requesting an appointment for:
Birth Date
Zip Code
Zip Code
Zip Code
Zip Code
Appointment Form Only
Business Street
Address - Required City, State
Please check which is applicable:
Agent's E-Mail Address
Agent's Name (last name first)
Business Phone
Business Fax
Social Security Number
Section I - Agent
Resident Street Address Resident City, State
Agency Non-Resident State License(s) Number
Social Security Number
- Agency
Agency Name Agency Tax I.D. Number
Principal Officer's Name
Agent Non-Resident State License Number(s)
Business P.O. Box number if applicable PO Box City, State
Business Street
Address - Required City, State
Please Type or Print Clearly
Section III - Licensing
Agent Resident State License Number Agency Resident State License Number
License Number
MetLife Group Life/Health/Disability
Metlife Individual Disability Income
MetLife Group Long Term Care Safeguard DHMO (only available in CA, FL, TX & NV)
Agent
Agency
Both
State
2
You are requesting an appointment with Metropolitan Life Insurance Company
Business Phone
Business Fax
Section II
ID - INST BUS PAI (10/08)
mm/dd/yy
MetLife
3
Appointment Form
III. Background Information (Attach a written explanation, including date of event and discharge, for yes answers.)
Yes
1. Do you have any prior affiliation with MetLife, MetLife Investors, New England Financial,
Walnut Street Securities, General American, or any of their affiliates?
If yes, please indicate which company__________________________________________
2. Are you covered under your company's Errors and Omissions (E&O) policy?
If not, attach the declaration page of your E&O policy.
3. Have you ever been convicted of any felony?
If said felony conviction was related to dishonesty or breach of trust, have you received,
subsequent to such conviction, written consent from an authorized insurance regulator
that you may be employed in the insurance industry? If yes, attach a copy of such consent.
4. Has the FINRA or any Federal or state regulatory agency ever:
(a) found you to have made a false statement or omission or been dishonest, unfair, or
unethical?
(b) found you to have been involved in a violation of investment- OR insurance-related statutes
or regulations ?
(c) found you to have been a cause of an investment- OR insurance-related business having its
authorization to do business denied, suspended, revoked, or restricted?
(d) entered an order against you in connection with investment- OR insurance-related activity?
(e) denied, suspended, or revoked your registration or license or otherwise prevented you
from associating with an investment- OR insurance-related business, or disciplined you by
restricting your activities?
(f) revoked or suspended your license as an attorney, accountant, or federal contractor?
5. Has any foreign government, court, regulatory agency, or exchange ever entered an
order against you related to investments or fraud?
6. Have you ever been or are you currently the subject of an investment related, insurance
related, or consumer-initiated complaint?
7. Have you ever been discharged or permitted to resign because you were accused of:
(a) violating investment- OR insurance-related statutes, regulations, rules or industry standards
of conduct?
(b) fraud or the wrongful taking of property?
8. Have any contracts that you held with any insurance companies been cancelled for
cause (not including productivity)?
9. Has any policy or application for errors and omissions insurance on your behalf ever been
declined, canceled, or renewal refused?
10. Have you ever had any of the following: sought protection from creditors; declared
bankruptcy, had a lien or judgement, had a creditor charge off an account/payables as bad debt
or uncollectible, or had any other problems in your credit history?
11. Are you under any legal order/judgement to make monetary payments to another person or
business entity or have you ever had your wages garnished?
No
ID - INST BUS PAI (10/08)
MetLife
4
IV.
IMSA Statement
The MetLife affiliated insurance companies (MetLife) are committed to conducting business with the highest ethical and
legal standards. We have established a tradition of integrity in dealing with our customers. MetLife has adopted the ethical
market of conduct program of the Insurance Marketplace Standards Association (IMSA). As described below, MetLife, all
employees and distributors are expected to observe the Principles and Code of IMSA:
1.
To conduct business according to high standards of honesty and fairness and to render that service to our
customers which, in the same circumstance, we would apply to or demand for itself.
2. To provide competent and customer-focused sales and service.
3. To engage in active and fair competition.
4. To provide advertising and sales materials that are clear as to purpose and honest and fair as to content.
5. To provide for fair and expeditious handling of customer complaints and disputes.
6.
To maintain a system of supervision and review th
at is reasonably designed to achieve compliance with
these principles of ethical market conduct.
V.
Acknowledgement and Authorization
I hereby certify that I have read and understand the items on this appointment form and that my answers are true and
complete to the best of my knowledge. I have been advised that MetLife, Inc., Metropolitan, General American, Walnut
Street Securities, MetLife Investors, and New England Financial and their affiliates (hereafter referred to as "The
Companies") may conduct investigations in connection with my request to represent The Companies in the solicitation of
certain insurance products. I authorize an inquiry to be made of all sources deemed appropriate by The Companies for the
purpose of obtaining information concerning my business practices and ethics, background, credit history, and financial
status, including, but not limited to, my record, if any, on file with the FINRA Central Records Depository. Any
information that The Companies may obtain about me will be treated as confidential and may be shared with the appointing
general agent, if necessary. I release the broker/dealer and/or its agents and any person or entity, which provide information
pursuant to this authorization, from any and all liabilities, claims or lawsuits in any matter related to the information
obtained from any and all of the above referenced sources used.
I understand that no right to commission or other compensation shall arise or exist until I have been appointed and all due
diligence successfully approved. If I am approved, I shall accept as full compensation for all services to be performed by
me, the compensation provided in the applicable commission and compensation schedule as issued, substituted or changed.
As an appointed agent/broker, I shall observe and be bound by the rules and regulations of The Companies.
FAIR CREDIT REPORTING ACT - As part of its regular procedures, The Companies may obtain an investigative
consumer report. It may deal with character, reputation, personal traits and life style. It may involve personal interviews
with friends, neighbors and associates. I understand I have the right to make, within a reasonable amount of time, a written
request for details on the name and address of the agency making the report. I further understand that depending on the
state law, subjects of an investigative consumer report may have the right to: 1) request that they be interviewed in
connection with the making of the report; and 2) receive a copy of the report, upon request. My signature below constitutes
my agreement and authorization to above. I understand that if any of the material information I provided is found to be
incorrect or incomplete, it may be grounds for not appointing, contracting and termination and the discretion of The
Companies.
I agree to conduct my business in accordance with the IMSA Principles of Ethical Market Conduct.
Individual:
Printed Name Signature Date
If Corporation, Company Officer Please Sign Here:
Printed Name
Signature
Date
ID - INST BUS PAI (10/08)
mm/dd/yy
mm/dd/yy
INST BUS DISC (04/07) eF
L000728AX(exp0710)MLIC-LD
Reform Act Employment/Registration Disclosure/Authorization
MetLife Institutional Business
Broker Operations
Disclosure
By this document, Metropolitan Life Insurance Company discloses to you that a consumer report or an investigative consumer
report containing information as to your character, general reputation, personal characteristics and mode of living, may be
obtained for employment purposes and/or as part of the process of our consideration of your application to become licensed
or appointed to sell insurance or to become registered with the Financial Industry Regulatory Authority. A consumer report or
an investigative consumer report may be secured as part of a pre-employment background investigation and at any time during
your employment. Should an investigative consumer report be requested, you will have the right to demand a complete and
accurate disclosure of the nature and scope of the investigation requested, and a written summary of your rights under the Fair
Credit Reporting Act.
Acknowledgment and Authorization
I acknowledge receipt of a separate document setting forth the above disclosure by Metropolitan Life Insurance Company, that
a consumer report or an investigative consumer report may be obtained by it for employment purposes and/or as part of the
process of its consideration of my application to become licensed or appointed to sell insurance or to become registered with the
Financial Industry Regulatory Authority. A consumer report or an investigative consumer report may be secured as part of its pre-
employment background investigation, and at any time during my employment. I authorize the procurement of such consumer
reports by Metropolitan Life Insurance Company for the purposes disclosed to me. If I am hired, or if I am already employed, this
authorization will remain on file and will serve as an on-going authorization for Metropolitan Life Insurance Company to procure
such consumer reports at any time during my employment.
I hereby authorize Metropolitan Life Insurance Company and MetLife Securities, Inc. to query my record, if any, on file with the
Financial Industry Regulatory Authority.
Signature of Applicant/Employee:_________________________________________________________________________
Printed Name of Applicant/Employee: _____________________________________________________________________
SSN of Applicant/Employee: _____________________________________________ Date: ___________________________
Witness Signature: _______________________________________________________________________________________
Printed Name of Witness:_________________________________________________________________________________
(10/08)
mm/dd/yy
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MetLife Appointment Form Only (Dickerson Insurance Services)

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Completed 1 June 2021

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