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Register - Partner Account
1
Funeral Home and Address
2
Primary contact details
3
Business Overview
Branch
None
abc
AR/Arkansas
Branch
FL
Illinois
Indiana
Kansas
Kentucky
LA/Louisiana
Minnesota
New Jersey
New Mexico
New York-Branch
North Carolina
Oklahoma
Sample branch 2
Sample branch1
South Carolina
Texas_SG
Virginia
Virginia
Washington
Name of the Business
*
Physical Address 1
*
Physical Address 2
*
Physical Address 3
Postal Code
*
Country
*
State
*
City
*
Main Business Telephone
*
Business License
*
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Salutation/Title
SELECT
Mr.
Mrs.
Miss
Ms.
First Name
*
Middle Name
Last Name
*
Mobile Phone
*
Email
*
Designation
Is your office located at the business address given on prior screen?
Yes
No
Office Address 1
*
Office Address 2
Office Address 3
Office Postal Code
*
Office Country
*
Office State
*
Office City
*
Is your business also registered as an insurance agency?
*
Yes
No
Insurance License
*
License Status
*
Active
Expired
Expiration Date
*
Designated Home State
*
Select State
License type
Limited (dollar amount and/or insurance type restriction)
Full (any life product, any dollar amount)
Required Document Uploads
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Month/Year established
*
Number of Funeral Directors/Embalmers on staff
*
Number of casketed funerals annually
*
Number of cremations annually
*
Annual preneed volume
*
$
100 - 1,000
1,000 - 10,000
10,000 - 100,000
100,000 - 1,000,000
1,000,000 - 10,000,000
State Issued Driver License
Producer Agreement
Direct Deposit Authorization
Producer Compensation Schedule
Explanation of Information found on MIB
Other Supporting Documentation
Add
State Issued Driver License
Producer Agreement
Direct Deposit Authorization
Producer Compensation Schedule
Explanation of Information found on MIB
Other Supporting Documentation
Remove
I hereby authorize Cyrus Life or an Agency appointed by Cyrus Life to verify the submitted records.
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