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Section X. Agent(s) Certification
Agent shall list any health insurance policies they have sold to the Primary Applicant.
1. List policies sold which are still in force (if this does not apply, state “None”) ______________________________________________
2. List policies sold in the past five (5) years which are no longer in force (if this does not apply, state “None”) _______________________
_______________________________________________________________________________________________________
3. Have you submitted any Applications or have knowledge of any Applications submitted for the Primary YES NO
Applicant that have been declined? If YES, please explain ________________________________________________
4. Have you reviewed the Application for correctness and omissions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Was the Application completed by you in the Primary Applicant’s physical presence? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. Was the Application completed by you over the phone? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7. Do you have knowledge or reason to believe the replacement of existing insurance may be involved? . . . . . . . . . . . . . . . . . . . .
8. I certify that I have provided the Primary Applicant with the following documents:
a. Application Packet (Phone Sales only) b. Outline of Coverage c. Other _________________________________________
I further certify that I have delivered the documents to the Primary Applicant (check all that apply; must select at least one):
In person Date __________ Mail Date ___________ Email Date __________ Fax Date ______________
Other (explain)______________________________________________________________________ Date ______________
I certify that I have interviewed the Primary Applicant, asked all of the questions as written on the Application, and I have truly and
accurately recorded on the Application the information supplied to me by the Primary Applicant.
Printed Name of Licensed Agent Signature of Licensed Agent Writing Number FL Agent License ID Percentage
Printed Name of 2nd Licensed Agent Writing Number FL Agent License ID Percentage
LY-LSCH-APP-B-FL Page 5 of 5 09/14
Agent shall list any health insurance policies they have sold to the Primary Applicant.
1. List policies sold which are still in force (if this does not apply, state “None”) ______________________________________________
2. List policies sold in the past five (5) years which are no longer in force (if this does not apply, state “None”) _______________________
_______________________________________________________________________________________________________
3. Have you submitted any Applications or have knowledge of any Applications submitted for the Primary YES NO
Applicant that have been declined? If YES, please explain ________________________________________________
4. Have you reviewed the Application for correctness and omissions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Was the Application completed by you in the Primary Applicant’s physical presence? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. Was the Application completed by you over the phone? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7. Do you have knowledge or reason to believe the replacement of existing insurance may be involved? . . . . . . . . . . . . . . . . . . . .
8. I certify that I have provided the Primary Applicant with the following documents:
a. Application Packet (Phone Sales only) b. Outline of Coverage c. Other _________________________________________
I further certify that I have delivered the documents to the Primary Applicant (check all that apply; must select at least one):
In person Date __________ Mail Date ___________ Email Date __________ Fax Date ______________
Other (explain)______________________________________________________________________ Date ______________
I certify that I have interviewed the Primary Applicant, asked all of the questions as written on the Application, and I have truly and
accurately recorded on the Application the information supplied to me by the Primary Applicant.
Printed Name of Licensed Agent Signature of Licensed Agent Writing Number FL Agent License ID Percentage
Printed Name of 2nd Licensed Agent Writing Number FL Agent License ID Percentage
LY-LSCH-APP-B-FL Page 5 of 5 09/14
