New Team Member Request 0620

Validation
You should have received an email from us that contained a Validation Code and a hyperlink to this web form.

Please enter both the Validation Code and your Email Address where this email message was received.
Validation Code*
Personal Email Address*
Enter the Personal Email Address where you received the email with the above Validation Code.

Personal Info
Full Name*
Enter your full legal First and Last name. Please do not enter any nicknames in this field.
First Last
Preferred First Name*
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.
Home Address*
Enter your current Home or Residence Address.

Street Address City State ZIP Code
Date of Birth*
Enter your Date of Birth (mm/dd/yyyy)
SSN*
Enter your Social Security Number.
Work Phone*
Enter the best Work Phone Number, the number you'd like us to try first to reach you directly.
Cell Phone*
Enter your cell phone number. This is used for user authentication for your Firefly email account, agency systems, and some carrier websites.
Role*
What will be your role in your office's agency operations?
- CSR - Service Accounts
- Producer - Sale and Service Accounts
- Additional Principal (Owner) of Branch

Insurance License
Active Individual Insurance License*
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.
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*
Enter your individual National Producer Number (NPN).
Full Name on License*
Enter your name EXACTLY as it appears on your individual resident insurance license.
Resident License State*
Select the state of your individual Resident Insurance license.
Resident License Number*
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*
Enter the EFFECTIVE DATE of your individual Resident State Insurance License (mm/dd/yyyy)
Expiration Date of Resident License*
Enter the current EXPIRATION DATE of your individual Resident State Insurance License. (mm/dd/yyyy)
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: 7 MB, Max. files: 3.

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*
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, carriers you are familiar 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*
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 do exist.
- No, I will not have any active P&C appointments.
- Yes, I will have active P&C appointments.
List Existing P&C Appointments*
If yes, list the P&C carriers with which you will have an active appointment upon joining Firefly.
Non-Competes*
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*
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.

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*
Relationship of Emergency Contact to You*
How is this emergency contact related to you?
- My spouse
- My partner
- My parent
- My child
Phone Number of Emergency Contact*
In the event of an emergency, we will first try to reach this emergency contact by phone.
Email of Emergency Contact
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.

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

Join a Firefly Agency office.

Contract Information - New Team Member

Validation

Personal Info

Insurance License

Personal Resident Insurance License

Background

Emergency Contact

Additional Info