Get Fraternal Agent License Appointment Individual Application - Ct.gov

This guide provides a detailed overview of how to complete the Fraternal Agent License Appointment Individual Application for use in Connecticut. By following these instructions, you will successfully navigate the application process and ensure that all necessary information is accurately provided.

Follow the steps to complete your application online.

1. Press the ‘Get Form’ button to access the application and open it in your preferred editing tool.
2. Begin by entering your social security number in the designated field.
3. Input your date of birth using the provided format: month, day, and year.
4. Fill in your last name, including any suffixes such as Jr. or Sr. if applicable.
5. Enter your first name and middle name in the specified fields.
6. Provide your complete residence or home address, including street address, city, state, and zip code.
7. List your home phone number and email address for future correspondence.
8. Indicate your gender by circling the appropriate option.
9. Answer whether you are a citizen of the United States, and if not, ensure you supply your work authorization.
10. Complete the fields related to your business name and address, including phone, fax, email, and website if applicable.
11. Check all lines of authority you are requesting from the Fraternal Benefit Society.
12. Have the Fraternal Benefit Society fill out their certification section, including their name, address, contact email, and signature.
13. Provide details of your present occupation and employer, and specify the percentage of time you intend to devote to the solicitation of fraternal insurance.
14. Respond accurately to the background information questions regarding any convictions or administrative proceedings, and attach necessary documentation if applicable.
15. In the applicant’s certification section, carefully read through all statements and ensure your original signature is provided along with the date.
16. Once you have filled out the entire application, save your changes. You can then choose to download, print, or share the completed form.

Complete your application online to ensure a smooth licensing process.