LifeSecure Agent Appointment
For Agent Use Only. Not For Solicitation Purposes
LS-0316 ST 10/08
LifeSecure Insurance Company – Brighton, MI
Policy Series LS-0002
Step 1 Agent QUICK Appointment
Quick Appointment Process

One page Appointment Process with proof
of LTC CE at the time of Quick Appointment

Agent 6-digit writing number & access to
Agent Portal

180 days to submit 1st LTC application

Upon submission, full agent appointment
package is required

Agent commissions may be delayed if full
appointment paperwork is not received in a
timely manner

Quick appointment is not available in the
following state(s): NM & PA. Also not
available when submitting a Worksite or
Group/Association case
For Agent Use Only. Not For Solicitation Purposes
Step 2 Agent FULL Appointment
Agent Appointment Checklist

LifeSecure Agent Appointment Application

Commission Schedule “Exhibit 3”

Distribution Partner Hierarchy Form

LifeSecure Selling Agreement

ACH w/void check or deposit slip

Personal IRS W-9 Form

Assignment of Commissions Form, if
applicable

Copy of ACTIVE insurance license(s)

Copy of LTC CE training & partnership
training, according to state regulations
For Agent Use Only. Not For Solicitation Purposes
Agent Appointment Application – Page 1
Agent Appointment Application

This is a 5 page document

There are questions requiring your response
on pages 1, 2, 3 & 5

Here on page 1 your MGA/Distribution
Partner may pre-fill their information
For Agent Use Only. Not For Solicitation Purposes
Agent Appointment Application – Page 2
Agent Appointment Application

On page 2 please be sure to complete the
“Licensing Information” section

You may be appointed in up to 3 states at
initial appointment

Copies of ACTIVE insurance licenses are
required for each state

New states may be added with the
submission of business and a copy of an
active insurance license in that state, plus
the state required LTC CE training/
partnership training
For Agent Use Only. Not For Solicitation Purposes
Agent Appointment Application – Page 3
Agent Appointment Application

On page 3 please be sure to complete the
“General Information” section
For Agent Use Only. Not For Solicitation Purposes
Agent Appointment Application – Page 5
Agent Appointment Checklist

Page 5 requires the agent’s signature
For Agent Use Only. Not For Solicitation Purposes
Agent Commission Schedule
Agent Commission Schedule

Provides selling agent commission
information

Please note: the different commission levels
based upon applicant age, premium
payment method and client type – Individual
vs. Multi-Life clients

States can have specific guidelines
For Agent Use Only. Not For Solicitation Purposes
Distribution Partner Hierarchy Form
Distribution Partner Hierarchy

Provides Distribution Partner organization
hierarchy information

This form and information is provided by
your distribution partner and is used to place
you (the writing agent) within the
organization hierarchy
For Agent Use Only. Not For Solicitation Purposes
LifeSecure Agent Selling Agreement – Page 1
LifeSecure Selling Agreement

The selling agreement is 13 pages in
length. The selling agreement outlines the
obligations and responsibilities of both the
agent and LifeSecure

Agents must provide information on pages
1 and 8

Here on page 1 agents must provide their
personal information, not agency
information
For Agent Use Only. Not For Solicitation Purposes
LifeSecure Agent Selling Agreement – Page 8
Agent Selling Agreement

Page 8 requires the agent’s signature
For Agent Use Only. Not For Solicitation Purposes
ACH – Direct Deposit Form
ACH – Direct Deposit Form

LifeSecure pays ALL commissions via
electronic fund transfer (EFT)

Please attach a copy of a void check or
bank account deposit slip. This is only used
to verify routing and account numbers
For Agent Use Only. Not For Solicitation Purposes
W-9 Form
W-9 FORM

The W-9 form is 3 pages in length and
requires responses on pages 1 & 3

The W-9 form must be completed by ALL
agents, including those agents requesting
assignment of their commissions, but
remain eligible for the LifeSecure Rewards
Program and contests!
For Agent Use Only. Not For Solicitation Purposes
Assignment of Commissions Form
Assignment of Commissions


The “Assignment of Commissions” form is
required only when an agent is requesting to
assign their commissions to another person
or entity.
The “Assignor” is the Agent and the
“Assignee” is the person or entity the agent
is assigning their commissions to.
For Agent Use Only. Not For Solicitation Purposes
LifeSecure Appointment Process Review!
QUICK
FULL
Agent Appointment Process
Agent Appointment Checklist

One page Appointment Process with
proof of LTC CE at the time of Quick

LifeSecure Agent Appointment Application

Commission Schedule “Exhibit 3”

Distribution Partner Hierarchy Form

LifeSecure Selling Agreement

ACH w/void check or deposit slip

Personal IRS W-9 Form

Assignment of Commissions Form, if
Appointment

Agent 6-digit writing number & access to
Agent Portal within 48 hours

180 days to submit 1st LTC application

Upon submission, a full agent
appointment package is required


applicable
Commissions may be delayed if full
appointment paperwork is not received

Copy of ACTIVE insurance license(s)
Quick appointment is not available in the

Copy of LTC CE training/Partnership
following state(s): NM & PA
training, as required by state
For Agent Use Only. Not For Solicitation Purposes
LifeSecure Agent Compliance Manual
For Agent Use Only. Not For Solicitation Purposes
Questions?
Please contact your Agent Support
Call Center between the hours of
8:30 AM and 6:00 PM (EST)
Toll free: (866) 582-7701
OR (810) 220-8770
For Agent Use Only. Not For Solicitation Purposes