Become an L.A. Insurance Franchisee Join the team! Get StartedSell your Existing Franchise Your Full Name First Middle Last Your Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Country of CitizenshipAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsPrimary Phone NumberEmail Address Education BackgroundHighest Education Level AchievedGEDHigh SchoolSome CollegeAssociates or Undergraduate DegreeGraduate or Postgraduate DegreeOtherPrefer Not to Answer"Other" Education Level DetailsDegree AttainedAssociate DegreeBachelor's DegreeMaster's DegreePostgraduate Degreen/aSchool Attended Year Started Year Completed Insurance BackgroundAre you currently a licensed insurance agent?Yes, I am a licensed insurance agent.No, I am not a licensed insurance agent.National Producer Number Please enter your NPN here. You can find your National Producer Number on NIPR's website here: https://nipr.com/help/look-up-your-npnLicense Number Please enter your insurance license number here.Carrier AffiliationsPlease enter the names of all carriers with whom you are affiliated or appointed. Separate carrier names with a comma.Have you had an Appointment Revocation in the last 5 years?NoYesRevoked Carrier AppointmentsIf you've had an Appointment Revocation in the last 5 years, please list all applicable carriers.Have you been involved in litigation in the last 5 years?No, I have not been involved in any litigation in the last 5 years.Yes, I have been involved in litigation in the last 5 years.Have you declared bankruptcy in the last 7 years?No, I have not declared bankruptcy in the last 7 years.Yes, I have declared bankruptcy in the last 7 years.Have you ever been convicted of a felony?No, I have never been convicted of a felony.Yes, I have a felony conviction on my record.Please explain your felony conviction(s):Current Employment InformationCurrent Employment StatusEmployed Full-TimeEmployed Part-TimeSelf-employedNot employed but looking for workNot employed and not looking for workHomemakerRetiredStudentPrefer Not to AnswerCurrent Employer's Name Your Current Job Title How long have you been with this employer? Please describe the nature of this businessEmployment HistoryPrevious Employer's Name Your Previous Job Title How long were you with this employer? Please describe the nature of this businessThe OpportunityHow many locations do you want to open?Please enter a number from 1 to 99.Will you work full time in the business?YesNoWill this franchise be your sole income?YesNoWill you have partner(s)?YesNoPlease indicate how many partners you anticipate having:Please enter a number from 0 to 99.Viability & QualificationA minimum net worth of $250,000 is required. Does your net worth meet or exceed this threshold?Please SelectYesNoI don't knowA minimum liquid asset base of $100,000 is required. Is this available to you?Please SelectYesNoI don't knowThe average franchise startup cost is $50,000. Is this available to you?Please SelectYesNoI don't knowA Franchise Fee of $10,000 is required at time of closing. Is this available to you?Please SelectYesNoI don't knowAre you able and willing to close on the Franchise Agreement within 90 days of completing this form?Please SelectYesNoI don't knowAlmost done!Do you have any other comments or questions you'd like to include?YesNoOther Comments and Questions:CommentsThis field is for validation purposes and should be left unchanged.
