USA-678a For Broker/Dealer use only (R-12/2014)
Allianz Life Insurance Company
of North America
5701 Golden Hills Drive
Minneapolis, MN 55416-1297
Registered Representative Appointment Request
Producer Data Sheet
Appointment requested for the following state
Resident state ________________________________________________________________________________________________________
Non-resident state______________________________________________________________________________________________________
If requesting non-resident FL appointment, please list county(ies) if known: ________________________________________________________
Please note: If the appointment is requested in the state of New York, complete the Allianz Life Insurance Company of New York Producer Data Sheet.
In order to sell an Allianz Life Insurance Company of North America (Allianz) product, a representative must be licensed and appointed,
depending on state guidelines, prior to soliciting business.
Representatives must be life, annuity and variable licensed depending on the state regulations.
To become appointed for Allianz variable and fixed products sold through your Broker Dealer, please submit the following:
1. This entire form must be completed and signed in order to process the appointment.
2. A copy of the representative’s CRD Form or U-4 Status Report, if available.
Please validate if your state requires NAIC Suitability Training prior to solicitation.
Representative’s signature Date
Name of broker/dealer ________________________________________________________ CRD#: __________________________________
Name ______________________________________________________________________________________________________________
Social Security number __________________________________________ Date of birth ____________________________________________
Resident address ______________________________________________________________________________________________________
City _________________________________________________________ State______________________________ ZIP code ____________
Business telephone ____________________________ Ext. __________________ Fax _____________________________________________
E-mail address ________________________________________________________________________________________________________
Business address ______________________________________________________________________________________________________
City _________________________________________________________ State______________________________ ZIP code ____________
Personal information:
Business information:
Fax to: 763.765.6323, Attn: Licensing
Mail to: Allianz Enterprise Producer Services: Variable Licensing, P.O. Box 561, Minneapolis, MN 55416-1297
Questions: Allianz Enterprise Producer Services Licensing, at 800.226.0574 or e-mail producerservices@send.allianzlife.com
