Producer Profile

Please complete the following information. All information will be kept in strict confidence. Information will be securely sent to Agency Relations at AF Group.

Items marked with an asterisk are *Required

Agency Information

Agency Code (if known) Agency FEIN/SSN (SSN only if sole proprietor) * Agency Name * Agency Address * Agency City *

Agency State *

Agency Zip *

Producer Information

Producer Name * Producer Title * Producer Email * Producer Home Address * Producer City *

Producer State *

Producer Zip * Social Security Number * Date of Birth (mm/dd/yyyy) * National Producer Number * (Look up your NPN) Name Changes

Background Information

Any "YES" answer to the following questions requires a separate explanation, including dates, locations, basis of charge and legal documentation indicating disposition of case.

1. Have you filed for, or been discharged from, any bankruptcy (including personal bankruptcy), insolvency or assignment for the benefit of creditors with a filing or discharge date, whichever in later, in the last five (5) years? * 2. Do you have delinquent unpaid debts exceeding, in total, $10,000? (add together delinquent: consumer debt, tax liens, loans, child support payments, alimony payments, civil judgments, and other delinquent debt.) * 3. With the exception of situations specific to continuing education, have you ever been the subject of an administrative proceeding regarding any professional, or occupational license that resulted in disciplinary action? * 4. With the exception of situations specific to continuing education, has your insurance license ever been suspended by, subject to a consent order from, revoked by, or surrendered to, any regulatory agency, or have you ever been fined, penalized, sanctioned or subject to any other disciplinary action by a state or federal regulatory agency or self regulatory organization or are you currently under investigation as a result of your activities in the business of insurance, securities, banking, investment banking or real estate? * 5. Have you ever had an insurance agency contract or any other business relationship with an insurance company terminated for any alleged misconduct? * 6. Have you ever been arrested, convicted of, pled guilty or nolo contendere to, or received deferred or suspended judgment or sentence for, any felony or misdemeanor other than a minor traffic violation? * 7. Are you now the subject of any complaint, investigation or proceeding that could result in a "yes" answer to any of the previous questions? *

Attestation

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.

Producer Signature * Date (mm/dd/yyyy) *