Agent Application

Full Name

Email *

Phone *

Street Address

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State

Country

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Virgin Islands, U.S.
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Postal code

Do you currently hold a Life & Health insurance license? *

Yes

If yes, which states are you licensed in? (seperate using commas)

How many years of experience do you have in the insurance industry? *

0-1 years

2-4 years

5+ years

What type of insurance have you primarily sold? (Check all that apply) *

Life Insurance

Annuities

Indexed Universal Life (IUL)

Health Insurance

Property & Casualty

Other

If other, specify here

Which carriers have you worked with? (separate them using commas) *

What was your personal annual production last year (estimated total premium written)? *

Under $50k

$50k - $99k

$100-$249k

$250k+

What is your average monthly premium written? *

How do you typically generate leads? (Check all that apply) *

Warm market

Purchased leads

Referrals

Social Media Marketing

Cold calling

Other

If other, please specify

What interests you about joining Freedom Insurance? *

What are your income goals for the next 12 months? *

Are you open to following a structured sales process and training to improve performance? *

Yes

On a scale of 1-10, how committed are you to scaling your business and hitting six-figure earnings? *

1
2
3
4
5
6
7
8
9
10
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What are your personal values, and why are they important to you? *

Are you currently contracted with another IMO or insurance company? *

Yes

If yes, are you able to obtain a release if needed?

How soon are you looking to make a transition? *

Immediately

30 days

60 days

Are you available for a 15-minute introductory call to discuss next steps? *

Yes

Agent Application

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