| 1.Have you ever been disciplined by a state insurance department?*
|
No
Yes
|
| 2.Have you ever had your insurance license, securities license, or other fiduciary
license suspended or revoked, or have you ever had an application for an insurance
license denied by an insurance department?*
|
No
Yes
|
| 3.Have you been discharged from any employment or had an agent contract terminated
for reasons other than low production?*
|
No
Yes
|
| 4.Have you ever been denied an appointment with any insurance company?*
|
No
Yes
|
| 5.Have you ever been denied appointment or renewal appointment by any insurance
and/or managed care company?*
|
No
Yes
|
| 4.Have you ever been terminated for cause by any insurance carrier?*
|
No
Yes
|
| 7.Has your license to sell insurance or HMO products ever been denied, suspended
or revoked by any state?*
|
No
Yes
|
| 5.Has any legal or regulatory body ever sanctioned, censured, penalized or otherwise
disciplined you?*
|
No
Yes
|
| 9.Have you ever filed an E and O claim?*
|
No
Yes
|
| 10.Have you been denied a bond or application for errors and Comission coverage with
any company?*
|
No
Yes
|
| 11.Have you ever been subjected to an insurance or investment related consumer initiated
complaint or proceeding?*
|
No
Yes
|
| 6.Have you or any of the partners, directors, offices or agents within your organization
every been fined, reprimanded, sanctioned or been the subject of a consent decree
in any state for violation of insurance laws, HMO regulations or other administrative
regulations? *
|
No
Yes
|
| 13.Have you or any or the partners, members, directors, officers or agents within
your organization ever been refused license to sell insurance/HMO, or has a license
to sell Insurance/HMO ever been suspended or revoked by any state?*
|
No
Yes
|
| 14.Has an E&O carrier ever denied claims, paid claims, or cancelled your coverage?*
|
No
Yes
|
| 15.Has a bonding or surety company denied, ever paid out on, or revoked a bond for
you? *
|
No
Yes
|
| 16.Have you ever paid a fine related to a consumer complaint, failure to renew you
license or continuing education credit in excess of $500?*
|
No
Yes
|
| 7.Have you ever been excluded, or are you aware of actions that could result in
exclusion, by the Office of Inspector General from participation in a government
healthcare program, including Medicare and Medicaid/Medi-Cal?*
|
No
Yes
|
| 8.Have you ever been cautioned or disciplined for violating a professional code
or ethics?*
|
No
Yes
|
| 9.Has any employer, insurance company, or securities, broker-dealer ever terminated
your employment or contract, or permitted you to resign for any other reason than
lack of sales?*
|
No
Yes
|
| 10.Have you ever had a complaint filed, a regulatory inquiry/investigation, an arbitration,
or been sued by an insurance department, NASD, state securities office, attorney
general or any other regulatory agency?*
|
No
Yes
|
| 11.If contracting with UNL, do you want your commissions advanced 6 months, paid as earned, or N/A?*
|
No
Yes
|
| If yes to any of the questions above, provide date of occurrence, brief details, and resolution:* |