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Welcome to Gradient! To get started, please fill out each of the forms in the tabs below.

Personal Information







Gender:








Residence Information







Business Information







Preferred Phone Contact:

Preferred Mailing Address:


*Please also send proof of completion

Available Annuity Contracts

Please indicate the companies you would like to contract with:


Athene (select below) ☀ ☉







Phoenix Life (select below) ☀













Legacy (select below) ☀

Oxford Life (select below) ☀ ☉


Available Life Insurance Contracts

Please indicate the companies you would like to contract with:




































☀ Company Requires E&O (agent name MUST be listed as the insured)
☉ Company Requires Voided Check


Background Information

Yes No 1. Have you ever been charged, convicted, or plead no contest to any crime or are there criminal charges pending against you or a business with which you are connected?
Please indicate if MISDEMEANOR and/or FELONY.
Yes No 2. Have you had, or do you currently have any outstanding collection accounts, judgments, liens, or garnishments against you or a business of which you were or presently are a principal? If yes, please provide the date of lien, initial amount, current amount and the payment amount on following page.
Yes No 3. Have you ever been a party to or have you personally violated any securities or commodities law or rule set by any securities or commodities regulatory body, organization, or employer in the commodities or insurance industry?
Yes No 4. Do you owe money to any insurance company, agency, manager or broker dealer, or have any business or personal debts that resulted in collections or charge-­offs?
Yes No 5. Have you or a firm in which you were a partner, officer, or director filed for protection from creditors, been declared bankrupt or insolvent, been a party to bankruptcy or receivership proceeding, compromised liabilities with creditors, or had a direct payment procedure initiated under the Securities Investor Protection Act?
Please indicate Chapter: 7, 11, 13 and the discharge date:
Yes No 6. Have you ever defaulted on a promissory note, or any other debt, including consumer or credit card debt?
Yes No 7. Have you ever been bonded?
Yes No 8. Are you currently bonded?
Yes No 9. Has a bonding or surety company ever denied, refused, paid out on, canceled, revoked or refused to continue a bond for you?
Yes No 10. If there any reason you cannot secure a bond?
Yes No 11. Has any insurance department, securities broker-­‐dealer, government agency, or self-­‐regulatory authority ever denied, suspended, revoked, censured, barred your license (as an insurance agent, attorney, accountant, or federal contractor) or registration, disciplined you with fines, entered an order against you, restricted your activities, canceled any contract or appointment with you or any other member, partner, officer or controlling persons in your organization or is there any pending disciplinary action?
Please indicate if DENIED SUSPENDED REVOKED CENSURED or BARRED.
Yes No 12. Have you ever had a claim filed against your Professional Liability or Errors and Omissions insurance coverage or has any E&O Carrier denied, paid claims on, or canceled your coverage?
Yes No 13. Have you had any complaints or deficiency claims filed against you by any insured/annuitant with any insurance company or state insurance department in the past 10 years?
Yes No 14. Have you ever used any other names or aliases on a license or other registration?
Yes No 15. Are you now or have you ever been employed by, or associated with to any degree directly or indirectly, a bank, savings and loan, or other financial institution?
Yes No 16. Are you now subject to any complaint, investigation, or proceeding which could result in a yes answer to any of the proceeding questions?

I have read the questions above and have answered them to the best of my knowledge.

Material Review Agreement

This Confidential Information Acknowledgment (the “Agreement”) is made effective, as of the date listed below, by and between Gradient Insurance Brokerage, Inc. (the “Company”)1 and the undersigned Financial Services Professional (“FSP”).
FSP acknowledges and agrees to the following:
  1. FSP may, by and through its relationship with the Company, receive or have access to certain confidential, proprietary, and/or non-°©‐public materials, information, or software of the Company, including but not limited to any and all any trade secrets or any oral, written, or electronic information or materials containing information regarding the Company’s business, operations, technology, know-°©‐how, ideas, concepts, marketing platforms, or clients (“Confidential Information”). By signing below, FSP agrees that FSP’s receipt of Confidential Information is subject to the provisions contained herein. All information provided to FSP by the Company, including marketing information and software, shall be deemed “Confidential Information,” irrespective of whether or not such information has been identified by the Company as such.
  2. All Confidential Information is and shall remain the exclusive property of the Company. FSP shall not, without the express prior written consent of the Company, disclose Confidential Information to any other person or entity (including any Broker-°©‐Dealer or Registered Investment Advisory Firm with whom FSP is affiliated) or permit any agent, employee, or affiliate of FSP to use or disclose Confidential Information to any other person or entity. FSP shall not use Confidential Information for any purpose other than FSP’s relationship with the Company, and agrees that all Confidential Information will ONLY be used for insurance, securities, or advisory business written through the Company or through another contracted member company of Gradient Financial Group, LLC. FSP agrees that all Confidential Information will immediately be returned upon the specific request of the Company.
  3. FSP agrees that FSP is solely responsible for FSP’s own licensure and regulatory compliance. By signing below, FSP: (i) agrees to only use Confidential Information in a manner that complies with the applicable federal, state, and local laws and regulations; (ii) agrees to comply with all applicable federal, state, and local laws and regulations in all other manners; (iii) accepts sole responsibility for FSP’s own use of Confidential Information; and (iv) acknowledges that the Company does not assume responsibility for or warrant the accuracy of any such Confidential Information, whether for compliance purposes or otherwise. Although Confidential Information may include general information on legal issues commonly encountered in the industry, FSP acknowledges that any such information provided to FSP by the Company is not legal advice and is being provided for self-°©‐help purposes only. The Company is not a law firm, it does not and cannot provide legal advice, and it is not a substitute for an attorney or law firm.
  4. This Agreement shall remain in effect indefinitely. FSP understands and acknowledges that unauthorized use or disclosure of any Confidential Information will cause irreparable damage to the Company, and FSP acknowledges that the Company may seek and obtain injunctive relief against the breach – or threatened breach – of the disclosure of any Confidential Information by FSP in addition to any other legal remedies that may be available.


Privacy Policy and Consent

Gradient Insurance Brokerage, Inc. (“Company”)1 employs physical, electronic and procedural controls in order to protect confidential information. Company may use personal information about you to assist Company in placing you with an annuity or life insurance company. Company will always restrict access to personal information to those who require it to provide products or services to you or to complete contracting requirements with certain annuity and life insurance companies. The only time Company will provide any information about you or your financial information is in these limited situations:
  • To complete transactions or account changes, as directed by you
  • To maintain or service your account
  • If requested by you
  • With entities under common ownership and control of Company
  • If Company is required or permitted by law or regulatory authorities with jurisdiction over Company
Again, your privacy is important. Company is dedicated to safeguarding your personal and financial information. Company maintains physical, electronic, and procedural safeguards to comply with federal standards to guard your confidential personal information.
Further, Company takes and records photos and videos during Company sponsored events. I hereby consent to the use of any such photo or video containing my image or likeness for Company’s own promotional or marketing needs.

1For the purposes of this Agreement, the term “Company” shall refer to Gradient Insurance Brokerage, Inc., along with any person or entity that directly or indirectly controls, is controlled by, is under common control with, or is associated through constructive ownership with the Company. The term “Company” shall also expressly include Gradient Financial Group, LLC and its contracted member companies.