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Reference Information

Please complete the following information regarding your personal references: Advise your references that an Authorized Representative may contact them for a Short Interview. Your references must be someone you have done business with and/or known for at least five years. They cannot be related to you or be licensed with any UNI preferred companies



(1) By federal law, UNI World Wide Financial Marketing . (UNI) is required to maintain social security numbers (SSN) for U.S. personnel and firms to whom UNI makes disbursements. The numbers you provide MUST correspond to the payee you have identified above.

Are you currently life licensed?

Are you currently securities licensed?

*Please bring copies of all your current licenses to:
UNI Worldwide Financial Marketing Co.
3805 Crestwood Pkwy NW
Suite 260
Duluth GA 30096
A: Have you personally or a firm that you exercised management control over or owned 10% or more of the securities of a company that failed in business, made a compromise with creditors, filed a bankruptcy petition or was declared bankrupt? (You are required to send a copy of original and/or discharge and repayment schedule if applicable)

B: Have you ever been convicted of, or pleaded guilty of, or been a nolo contender ("no contest") to:
1. a felony or misdemeanor involving insurance, investments, or a related business fraud, theft, breach of trust, false statements of omissions, wrongful taking of property, bribery, forgery, counterfeiting or extortion?

2. any other felonies?

C: Has any State Insurance Department, State or Federal Regulatory Agency, or any Self-Regulatory Organization ever:
1. entered an order against you relative to a violation of insurance or investment-related regulations or statutes?

2. fined, denied, suspended or revoked your license or registration?

D: Do you have any debit balances with another insurance agency, or unsatisfied judgments or liens (including tax liens) against you? If yes, provide details, supporting documentation including dollar amount outstanding, and schedule of repayment plan or final disposition.

E: Has a bonding company denied, paid out or revoked a bond for you?

F: Are you an employee, officer, director or agent of any bank, savings and loan association, mortgage company, investment adviser firm, insurance company/agency, broker/dealer, or other lending or financial institution?

G: Have you been discharged or permitted to resign because you were accused of violating investment related statutes, regulation rules or industry standard of conduct, fraud or wrongful taking of property?

H: Are you now the subject of any complaint, investigation, or proceeding that could result in a "Yes" answer to questions A-G?

I am, or will soon apply to become, a licensed producer of UNI Worldwide Financial Marketing (“UNI”). I agree to comply with the guidelines of UNI, including but not limited to the following: *
I will not solicit sales of insurance policies, directly or indirectly and I will not oversee representatives, unless and until I am fully and properly incensed and appointed.*
I will not represent to a customer, or train other representatives to represent to a customer, that an indexed life insurance policy or indexed annuity is a mutual fund.*
Upon approval from UNI, I will obtain copies of the applicable life insurance and/or annuity replacement procedures and forms, if any, required under the insurance laws of the state(s) in which I have an insurance agent license. I will review them and will comply with them. I will also truthfully and fully complete the information called for on a life insurance or annuity application and agent’s statement regarding replacements. I understand that under state insurance laws, “replacement” generally may include the purchase of a new policy where it is known or should be known to the proposing agent that, by reason of the new policy, an existing policy has been or is to be lapsed, forfeited, surrendered, terminated, reduced, or borrowed against.*
I will promptly deliver all policies and promptly remit all premiums.*
I will not use or provide any policy illustrations except those expressly authorized by the applicable life insurance company and UNI. I understand that illustrations of a life insurance policy are based on hypothetical rates, and indexed life hypothetical illustrations do not represent past or future investment results. I agree I will not use or represent such policy illustrations except as authorized by the life insurance company and UNI.*
I understand that I must complete a pre-licensing education course(s), either before obtaining a provider company appointment or within 120 days upon submitting paperwork to a product provider requesting an appointment. I further understand this is a requirement that must be completed prior to approval with UNI.*
I understand that I am not an employee of UNI and my relationship with UNI is that of an independent contractor. Even though I may be designated as an “employee” of UNI, such designation will not change the fact that by independent contractor, I understand that I will be responsible for paying any/all federal, state, city or other taxes that may become payable concerning any compensation I may receive from UNI.*
I understand and acknowledge that I earn income only from the sale of the Products and Services and no income is earned by or paid to me for recruiting. My sole compensation shall be commissions paid by, or caused to be paid by, UNI according to my Agreement with UNI and paid in the manner provided in, and subject to the terms and conditions contained in the commission schedules which are published by UNI. There is no guarantee that I will be financially rewarded solely by becoming a member of UNI. *
I also understand that UNI will publish guidelines and commission schedules from time to time which relate to sales position designations, performance standards, commission rates of UNI and other matters in the exercise of its sole discretion, and without notice, increase or decrease the rates and amounts of commissions or the sales position of the Associate provided. However, any such changes will only be prospective and affect any new business and any commissions earned thereafter.*
I understand that my commissions are a share of UNI’s commissions and that my commissions are earned by and shall be payable to me only after the order or application for Products and Services submitted by Representative is approved by UNI or a Preferred Company at its principal office, or by an approved UNI designee;
i) actual payment for the same has been made by and received from the Customer; and
ii) UNI has actually received payment from a Preferred Company, if applicable.*