Agent Contracting

Information needed to begin the contracting process

Complete this form to start your appointments with CJS Insurance Solutions and the carriers we represent. Average completion time: 5 minutes.

Your information

Match this to your insurance license exactly — it's used on every carrier appointment.

Full Name *

Full name required.

Payee Name (your name or LLC)

Used on 1099s and direct deposit. If you write under an LLC, list the LLC here.

Date of Birth *

Date of birth required.

Agent NPN *

Enter a valid NPN (4–10 digits).

Agent SSN *

Encrypted in transit

9-digit SSN required.

Mailing Address *

Mailing address required.

City *

City required.

State *

State required.

ZIP Code *

5-digit ZIP required.

Agent Phone Number *

Valid 10-digit phone required.

Email *

Valid email required.

State licensing information

Add every state where you maintain an active insurance license. Your resident state license number is required.

Do not list these as non-resident states: AR, GA, VA, KY, MD, CO. These are state exchanges — add them in the "Exchange States" section below if you'd like to sell there.

Active Licenses *

Email full license copies to chris@cjsinsurancesolutions.com.

State

License Number

License Type

Exchange State Licenses (optional)

If you hold licenses in any of the state exchanges below and want to sell there, check them. GA and AR are recommended.

Contract details

Confirm who's bringing you on and the commission level you've been quoted.

Contract Request Type *

Required.

Upline *

Select your upline.

Commission Level *

Required.

Desired Start Date

Leave blank to start as soon as appointed.

Carriers You Want Appointed With

Notes

0/2000

Review and submit

Double-check your information. Once submitted, we'll begin the contracting workflow within one business day.

Contracting request received.

We'll review your information and begin carrier appointments within one business day. You'll receive an email confirmation shortly. Email full license copies (resident state required) to chris@cjsinsurancesolutions.com.

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