Creators Application Form

Please complete the below to be considered for a Creators focused Protectors Pass

First Name *

Last Name *

Email *

Company *

Job Title *

Website URL *

Physical Address (for GDPR compliance) *

Which of the following best describes your company? (Please choose one) *

Insurance AgencyIMO / FMOInsurance CarrierIndex ProviderWealth PracticeRIACapital Provider (VC, PE, etc.)Bank / Wirehouse Insurance DeskOther (Please Specify):

Which of the following best describes you? (Please choose one) *

Independent Insurance AgentCaptive Insurance AgentAgency Owner / Principal

NPN *

I also have a CRD

CRD Number

Primary States (select your top 5–10) *
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Which of the following best describes you? (Please choose one) *

Independent Registered AdvisorNon-Securities Registered AdvisorBroker Dealer AdvisorNon-Client Facing Role

CRD *

I also have an NPN

NPN Number

Which of the following best describes you? (Please choose one) *

Independent Registered AdvisorNon-Securities Registered AdvisorNon-Client Facing Role

CRD *

I also have an NPN

NPN Number

I have an NPN

NPN Number

I have a CRD

CRD Number

Please briefly describe your role. *

Which of the following best describes your role and/or area of focus? (Please choose one) *

Life InsuranceAnnuityLife + Annuity (equal focus)Holistic PlanningWealth ManagementP&CProduct DevelopmentMarketingCompliance / Legal / RegulatoryActuarial / PricingTechnologyFinance / InvestingCorporate StrategyM&AOther (Please Specify):

What topics are most relevant to you? (Select all that apply)

Product AdoptionPersonal Branding / InfluenceOnline Lead GenerationOffline Marketing (Seminars, etc.)Recruiting AgentsSuccession PlanningSelling to Niche AudiencesAutomation (AI, etc.)ComplianceWhole LifeVariable LifeIndex Universal LifeFixed AnnuitiesVariable AnnuitiesUnderwritingInspirational MarketingLong Term CareGroup BenefitsCross SellingM&AOther (Please Specify):

I understand that participation may require attendance at sponsored sessions, sponsored roundtables, and/or visiting select sponsors' booths. *

YesNo

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