Counselor Information
Please complete our Counselor Information Profile with availability as below:-
Current Date *
MM
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DD
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YYYY
Name *
Your answer
Date of birth *
MM
/
DD
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YYYY
Gender *
Social Security number (optional)
Your answer
Business address (Addressline) *
Your answer
City *
Your answer
State - Zip *
Your answer
Business phone *
Your answer
Business fax *
Your answer
Email *
Your answer
Home address (please include city & state) *
Your answer
National Producer Number *
Your answer
Are you willing to submit to a background check? *
Do you have any felony or misdemeanor convictions? *
Do you have a criminal investigation or court case pending? *
Marital status *
Single, never married
Married or domestic partnership
Widowed
Divorced
Separated
Choose
Spouse Name *
Your answer
In case of emergency notify: *
Your answer
Do you have current E & O? *
Current types of licenses held *
Your answer
In what states are you licensed? *
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Select
Which Worksite Carriers have you represented? *
Allstate
Colonial
Transamerica
Trustmark
Unum
Other:
Select
What enrollment system have you used?: *
Benefits Selection/Selerix
Common Census
Plane.Biz
Trustmark
Other:
Select
What is the highest education level you attained? *
Your answer
Professional designations *
Your answer
Special skills *
Your answer
Please Rate your benefits knowledge in the following areas: *
No knowledge
Limited knowledge
Knowledgeable
Very knowledgeable
Expert knowledge
HSA/HRA’s
Legal
Universal Life
Accident
Critical illness
Short Term Disability
Long Term Care
401(k)/403(b)
Please rate your computer skills in the following: *
No Proficiency
Limited Proficiency
Proficient
Very Proficient
Expert Proficiency
Internet/Email
Typing/Data Entry
MS Word
MS Excel
MS PowerPoint
MS Access
Languages *
English
Spanish
Chinese
Vietnamese
Other
Select
401(k) Experience *
Sec. 125 experience *
Do you have a car available for local use? *
Do you have a car available for out of town use? *
Are you available for overnight trips? *
Do you have a means to pay for travel expenses? *
Longest period you could be out of town? *
Your answer
What is the minimum advance notice you need to work? *
Your answer
Are there potential problems for you working out of town (children, pets, parents, obligations)? *
How many years do you have in the enrollment industry as a Benefits Counselor? *
0-1 years
1-2 years
2-4 years
4-6 years
6-10 years
10+ years
Choose
Do you have a credit card in your name? *
Who referred you to PCI? *
Your answer
Industries enrolled? (schools, etc.) *
Your answer
Please list three enrollment company references *
Your answer
Work experience last five years *
Your answer
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