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Your Information
Join our network for the simplest solution to manage your life insurance business
First Step:
Please provide us with your Broker and Agency information.
Email Address
A broker with this email already exists. Please use a different email.
A user with this email already exists. Please use a different email.
Email is required.
Email Address is incorrect.
Please use the Avantax Email address.
First Name
First Name is required.
Last Name
Last Name is required.
Phone
Phone is required.
Invalid Phone Number.
State
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State is required.
Select a password
Password is required.
Re-enter Password
Confirm Password is required.
Passwords do not match.
Passwords must be at least 8 characters in length and contain at least 0 non-alphanumeric characters.
Security Question
Please choose a security question
What is your pet's name?
What year was your father born?
What year was your mother born?
What is your favorite color?
What is the artist of your favorite song?
What was your high school mascot?
What was the first concert you attended?
Where did you go to on your honeymoon?
What is your grandmother's first name?
Where do you want to retire?
What is the name of the college you attended?
What year did you graduate from high school?
What is the middle name of your youngest child?
What was your childhood nickname?
Where was your first job located?
Who was your childhood hero?
What is your favorite team?
What is your favorite movie?
What is your favorite sports team?
What is your last four digits of SSN?
Security Question is required.
Security Answer
Security Answer is required.
Next Step:
In order to confirm your licensing, please enter your National Producer ID and State OR your Social Security number and Date of Birth.
National Producer ID
National Producer ID is required.
State License
Choose File
Remove File
Please Attach State License.
OR
SSN
Invalid SSN.
SSN is required.
Date of Birth
Date of Birth is required.
Invalid date.
Age should be in 18 to 85.
Lastly:
Complete the process by downloading the signature authorization form, print, sign, upload the form, and click submit.
Broker Signature Authorization
Download Signature Authorization Form
Upload Form
Remove Form
Please Attach Signed Authorization Form.
Your password should contain
1 UPPER CASE
1 lower case
1 Number
8 Characters Minimum
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