JoinFirefly - Firefly

Ready to Join Firefly?
Full Name - Principal 1*
Enter your full legal First and Last name. Please do not enter a nickname in this field.
First Last
Preferred First Name - Principal 1*
What do you like to be called? Are you a Joseph that likes to be called "Joe"? A Jennifer that likes to be called "Jenn"? Tell us your PREFERRED FIRST NAME. This is the place to enter a nickname if you like to use one.
Personal Email - Principal 1*
Enter your personal email address.
Home Address - Principal 1*
Enter your current Home or Residence Address.

Street Address City State ZIP Code
Active Individual Insurance License - Principal 1*
Do you have an active individual Property & Casualty insurance license?
- No, I do not have an active insurance license.
- Yes, I have an active insurance license.
STOP! No individual insurance license?
STOP! You cannot oversee a Firefly Agency location without an active individual P&C insurance license. The person completing this form to sign up with Firefly must be a principal/owner of the entity that is being contracted, and they must hold and maintain an active insurance license.

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Entity License Info
Answer these questions about your ENTITY license. Do not enter information from your individual insurance license here, we'll ask about that later.
Entity NPN*
Enter the NPN (National Producer Number) of your ENTITY License.
Name on Entity License*
Enter the name of your entity EXACTLY as it appears on your ENTITY's Resident Insurance License.
State of Entity's Resident License*
Select the state in which your Entity holds a Resident insurance license.
License Number of Entity's Resident License*
Enter the LICENSE NUMBER of your entity's resident state insurance license. The license number should be visible on a copy of your license, though in some states the license number is labeled the "System ID" on the license. A few states will use the entity's NPN as the license number.
Effective Date of Entity's Resident License
Enter the EFFECTIVE DATE of your entity's Resident State Insurance License. (mm/dd/yyyy)
Expiration Date of Entity's Resident License*
Enter the EXPIRATION DATE of your entity's Resident State Insurance License. (mm/dd/yyyy)
Upload Entity Resident License
Use this tool to upload a PDF copy of your Entity's Resident Insurance License.
Drop files here or

Accepted file types: pdf, jpg, Max. file size: 64 MB, Max. files: 5.
No Entity License? Next: Office Info
Firefly pays commissions to the individual or entity that is contracted (signs a contract) with us. We cannot pay commissions to a legal entity that does not have an active insurance license. You can continue to complete the form, but we won't be able to complete your on-boarding until you have an Entity insurance license. You may choose to go back to page 1 of this form and change your Legal Entity Type to "Individual". If you contract with Firefly as an individual you don't need an entity license. However, we will be paying commissions to you individually rather than to your legal entity, so be aware of the tax implications of this change.

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Office Information
Tell us about your office, organization, and operation. This information is required to populate a Firefly contract and to get you setup in our systems.
Storefront Type*
We divide offices into two categories: 1.) Office Storefront: A "brick and mortar" office/storefront where clients can walk in to meet with you. 2). Digital Storefront: This is, well... anything else. Usually this is a "home office" with an emphasis on a stronger digital presence. If you do NOT have a "brick & mortar" office storefront, you have a "digital storefront".
- Office Storefront
- Digital Storefront
Office Physical Address*
Enter the PHYSICAL ADDRESS of your place of business. If you operate an Office Storefront, this is the address of your office location. If you operate a Digital Storefront, this is probably your home address.

Street Address City State ZIP Code
Office Mailing Address*
Enter your office's MAILING ADDRESS.

Office Mailing Address is the same as Physical Address

Street Address City State ZIP Code
Main Office Phone*
Enter the MAIN PHONE NUMBER of your office.
Website
If your office currently has a customer facing website, enter the web address (URL).
Next: Personal Info

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Personal Info
Next we'll need to get some information about you. You'll need to have your resident insurance license handy to complete this section. If your location has other owners, we'll ask about them later.
Date of Birth - Principal 1*
What is your Date of Birth. (MM/DD/YYYY)
SSN - Principal 1*
Enter your Social Security Number.
Work Phone - Principal 1*
Enter the best Work Phone Number, the number you'd like us to try first to reach you directly.
Cell Phone - Principal 1*
Enter your cell phone number. This is used for user authentication for your Firefly email account, agency systems, and some carrier websites.
T-Shirt Size - Principal 1*
We'd like to send you a FIREFLY T shirt to celebrate your coming aboard with Firefly! What is your preferred T Shirt size?

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Background
This section will ask you about your insurance background, and whether there are any carriers with which you cannot be appointed, whether the obstacle be an in-force non-compete, or for any other reason.
Insurance Background - Principal 1*
Provide a summary of your experience in the insurance industry. Many carriers ask for this info when evaluating your appointment. Please provide a summary of the types of agencies you have been a part of, past agency roles, Lines of Business you are experienced with, etc.
Carrier Experience*
List the carrier(s) that you've worked with in the past, the carriers with which you have experience. (You can list carrier names separated by commas)
Existing P&C Appointments - Principal 1*
Will you have any existing/active P&C carrier appointments upon joining Firefly? It is rare for this to happen, but we ask you to disclose them if they exist.
- No, I will not have any active P&C appointments.
- Yes, I will have active P&C appointments.
List Existing P&C Appointments - Principal 1*
If yes, list P&C Carriers with which you will have an active appointment upon joining Firefly.
Non-Competes - Principal 1*
Will you have any in-force non-competes (or carriers with which you cannot be appointed for other reasons) upon joining Firefly?
- No, there are no carriers with which I cannot be appointed
- Yes, there are carriers with which I cannot be appointed.
Non-Compete Details - Principal 1*
If you will have non-competes (or carriers with which you cannot be appointed for other reasons) upon joining Firefly, please provide a summary below. Be sure to include the carrier name, approximate start data, end date, and reasons for each non-compete.
Next: Personal Resident Insurance License

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Personal Resident Insurance License
Please tell us about your individual Resident State Insurance License. Your 'Resident' license is the one that we need to on-board you with Firefly. If you are licensed in any non-resident states, we will work on those states with you in the future, after you are on-boarded with Firefly.
NPN - Principal 1*
Enter your individual National Producer Number (NPN).
Full Name on License - Principal 1*
Enter your name EXACTLY as it appears on your individual resident insurance license.
Resident License State - Principal 1*
Select the state of your individual Resident insurance license.
Resident License Number - Principal 1*
Enter the LICENSE NUMBER of your individual resident state insurance license. The license number should be visible on a copy of your license, though in some states the license number is labeled the "System ID" on the license. In a few states, your license number will match your NPN.
Effective Date of Resident License - Principal 1*
Enter the EFFECTIVE DATE of your individual Resident State Insurance License. (mm/dd/yyyy)
Expiration Date of Resident License - Principal 1*
Enter the current EXPIRATION DATE of your individual Resident State Insurance License.
Upload PDF of Resident License
Use this tool to upload a PDF copy of your personal Resident State Insurance License.
Drop files here or

Accepted file types: pdf, jpg, Max. file size: 64 MB, Max. files: 4.
Next: Emergency Contact

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Emergency Contact
Please identify someone to act as your emergency contact. We will not contact this person unless, in an emergency, we are unable to contact anyone at your location, and we need to confirm your well-being and/or branch continuity.
Name of Emergency Contact - Principal 1*
Relationship of Emergency Contact to Principal 1*
How is this emergency contact related to you?
- My Spouse
- My Partner
- My Parent
- My Child
Phone Number of Emergency Contact - Principal 1*
In the event of emergency, we will first try to reach this emergency contact by phone.
Email of Emergency Contact - Principal 1
We will not email this person unless we are trying to confirm your well being and branch continuity but are unable to reach branch members. This email address is not used for any purpose other than to confirm branch continuity if we are unable to reach you.
Next: Additional Entity Principals
Almost Done!

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Entity Principal #2
Enter basic information about the SECOND Principal of your entity ("owners" or "shareholders" of a corporation, "members" of an LLC, "partners" in a partnership, etc.).
Legal Name - Principal 2*
Enter the Full Legal First and Last Name of entity principal #2.
First Last
Personal Email - Principal 2*
Enter the Personal Email Address of entity principal #2.
Home Address - Principal 2*
Enter the current Home Address of entity principal #2.

Street Address City State ZIP Code
Entity Principal #3
Enter basic information about the THIRD Principal of your entity ("owners" or "shareholders" of a corporation, "members" of an LLC, "partners" in a partnership, etc.).
Legal Name - Principal 3*
Enter the Full Legal First and Last Name of entity principal #3.
First Last
Personal Email - Principal 3*
Enter the Personal Email Address of entity principal #3.
Home Address - Principal 3*
Enter the current Home Address of entity principal #3.

Street Address City State ZIP Code

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Additional Information
Is there anything else that we should know about getting you on-boarded with Firefly?
Untitled

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Let's get started!

Step 1 of 10 - Ready to Join Firefly

Ready to Join Firefly?

STOP! No individual insurance license?

Legal Entity Info

STOP! Can't operate as an 'entity' w/o entity license

Branch Info

Entity License Info

No Entity License? Next: Office Info

Office Information

Next: Personal Info

Personal Info

Background

Next: Personal Resident Insurance License

Personal Resident Insurance License

Next: Emergency Contact

Emergency Contact

Next: Additional Entity Principals

Almost Done!

Entity Principal #2

Entity Principal #3