Become a Franchisee

All About You...

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Country of Citizenship*

Primary Phone Number*

Email*

Education

Highest Education Level Achieved*

School Attended

Year Started

Year Completed

Degree Attained

Insurance Background

Are you currently a licensed agent?*

Yes
No

Are you currently affiliated with a carrier?*

Yes
No

Which Carriers are you currently affiliated with?*

Please enter the insurance carriers with whom you are currently affiliated, separated by commas.

Have you had an Appointment Revocation in the last 5 years?*

Yes
No

Have you been involved in litigation in the last 5 years?*

Yes
No

Have you declared bankruptcy in the last 7 years?*

Yes
No

Have you ever been convicted of a felony?*

Yes
No

Please explain your felony conviction(s):

Employment History

Current Employer Name

Your Job Title

How long have you been with your current employer?

Nature of the business

Previous Employer Name*

Your Job Title*

How long were you with this employer?*

Nature of the business*

Previous Employer Name

Your Job Title

How long were you with this employer?

Nature of the business

The Opportunity

How many locations are you interested in opening?*

Please enter a number from 1 to 50.

Desired Territory -- First Preference*

City State / Province / Region

Desired Territory -- Second Preference*

City State / Province / Region

Desired Territory -- Third Preference*

City State / Province / Region

Will you work full time in the business?*

Yes
No

Will this franchise be your sole income?*

Yes
No

Will you have a partner(s)?*

Yes
No

How many partners will you have?

Please enter a number from 1 to 25.

Viability & Qualification

A minimum net worth of $250,000 is required. Does your net worth meet or exceed this threshold?*

Yes
No

A minimum liquid asset base of $100,000 is required. Is this available to you?*

Available
Not Available

The average franchise startup cost is $50,000. Is this available to you?*

Available
Not Available

A Franchise Fee of $10,000 is required at closing. Is this available to you?*

Available
Not Available

Are you able and willing to close on the Franchise Agreement within 90 days of completing this form?*

Yes
No

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All About You...

Education

Insurance Background

Employment History

The Opportunity

Viability & Qualification

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