D'Metrid James Financial Services — Agent Associate Application

Complete the steps below to submit your application and begin building your agency.

Step 1 — Review & Accept
Instructions for Completing Your Application
  1. Fill Out the Associate Application Please provide all of the requested Personal and Contact information and answer the questions in the Background Questionnaire. You can "Save" or "Exit" the application at any time and complete it later.
  2. Accept the Terms of Use For Biz To Biz Insurance Connect Please review and accept the terms of use for Biz To Biz Insurance Connect.
  3. Enrollment Processing Fee — $0.00 Your Associate Application will not be submitted to Biz To Biz Insurance until you click the "Submit and Complete My Application" button at the end of the application process and your payment of the enrollment fee has successfully been processed. Your card will not be charged unless your application is accepted and an account is created to access Biz To Biz Insurance Connect.
Before You Proceed, Have the Following Ready:
  1. Your Social Security Number. Biz To Biz Insurance and its affiliates and subsidiaries are required by Federal law to obtain your Social Security Number for tax reporting purposes. The number you provide must correspond to your legal name.
  2. Your Personal and Contact Information. This includes your current address, e-mail address, phone number, and date of birth.
  3. Credit Card Information. You will be asked to pay a non-refundable $0.00 enrollment processing fee as part of the Application. Please have the exact name on your credit card, expiration date, and billing address ready.
Important Disclaimers

All information submitted is subject to our Privacy Policy.

2

Create Application

Please fill out the fields below and an application will be created for you.
You will be able to come back to continue later. All fields are required unless otherwise noted.

A. Basic Information
First Name
Middle Name (optional)
Last Name
Suffix (optional)
Nickname (optional, first-name only)
E-mail Address
Retype E-mail Address
B. Background Information
1. Recruiter Information
Recruiter Agent Code
2. Personal Information
All fields are required unless otherwise noted.
Social Security Number
Retype SSN
Date of Birth
National Producer Number (optional)
Click here to find your National Producer Number
3. Contact Information
All fields are required unless otherwise noted.
Street Address
City
State
Zip Code
Phone
4. Background Questionnaire
If you answer "Yes" to any of the following, you will need to submit a detailed explanation before you can proceed. Please contact us to provide supporting documents.
A.

Have you ever been previously terminated by, or denied contracting through, Biz To Biz Insurance Solutions LLC OR any of its affiliate or subsidiary companies?

B.

Have you ever been convicted of, or plead guilty or no contest, in a domestic, foreign, or military court to committing or conspiring to commit a MISDEMEANOR OR FELONY involving any of the following: insurance, investments or a related business, fraud, theft, breach of trust, false statements or omissions, wrongful taking of property, bribery, forgery, counterfeiting, robbery, or extortion?

C.

Within the past 10 years, have you, or any organization or business in which you are or were an owner, partner, or officer, filed a personal or corporate bankruptcy petition or been the subject of an involuntary bankruptcy petition?

D.

Has any State Insurance Department, State or Federal Regulatory Agency, Foreign financial regulatory authority, or any Self-Regulatory Organization ever filed a complaint against you, suspended your registration or license, disciplined you, or prevented you from associating with a financial services-related business or restricted your activities?

E.

Do you have any debit balances with another insurance agency or insurance company, OR any unsatisfied court judgments or liens (including tax liens and liens for delinquent child support) against you?

F.

Have you or any business in which you are or were an owner, partner, or officer ever been found liable in any civil lawsuit or arbitration proceeding involving allegations of fraud, misappropriation or conversion of funds, misrepresentation, or breach of fiduciary duty?

G.

Have you or any business entity in which you are or were an owner, partner, or officer ever had an insurance producer or insurance agency contract or any other business relationship with an insurance company or insurance agency terminated involuntarily for any reason other than lack of sales?

H.

Are you currently an employee, officer, or director of any insurance carrier, investment adviser firm, FDIC insured bank, thrift, or credit union?

I.

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

5. Certification and Authorization

By typing my name below, I certify that all data in this Application, including my Social Security Number, is true and correct to the best of my knowledge.

In addition, by typing my name below, I hereby authorize Biz To Biz Insurance Solutions LLC and its affiliate companies to use and/or release the information provided in this Application to authorized employees, and/or contractors for the purpose of processing my Application, addressing licensing and compliance matters, and for other reasonable and necessary business purposes.

Your Name
Today's Date