Agency/Producer Appointment Form for Salus Insurance

Hide Section - Applicant Information

Applicant Information

Hide Section - Employment Information

Employment Information

  
Hide Section - Agency Business Information - 1

Agency Business Information - 1

Hide Section - Specialisations and Preferences

Specialisations and Preferences

  
Hide Section - Agency Business Information – 2

Agency Business Information – 2

Hide Section - File Upload *

File Upload *

    *
    Please upload one each of the following:
  • Certificate of State licensure for each state where you are seeking appointment
Hide Section - Signature and Certification

Signature and Certification

Finally, we’ll ask you to sign the form, certifying that the information you just provided is correct. You’ll have a chance to share any comments or questions at the end of the form, before you submit.

By my signature below, I certify that the information I just provided in this form is complete and accurate. If an appointment is offered to me and my agency, I understand that a background check may be conducted on me and all my staff members as part of the appointment process.

04/03/26