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§1 Your business

This appears on the letterhead and contact block.

§2 Licensing

What you're licensed to offer, and where.

§3 MGA & carriers

Who you place business through.

§4 Compensation

The standard commission language is always included. Add these only if they apply to you.

§5 Other business activities

Outside roles, ownership stakes, or income sources unrelated to your insurance practice.

§6 Ownership interest

This tool only includes standard ownership language. If there's an ownership interest to disclose either way, that needs custom wording — check with your MGA's compliance team before using this document.

§7 Review & generate

This tool doesn't verify anything you enter. You're solely responsible for the accuracy of your disclosure. If your licensing, carrier appointments, business structure, or outside activities change, come back and regenerate — most advisors should review this at least once a year, or sooner if something changes.
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Disclosure of Conflicts of Interest & Compensation

About Me

Products Available

Nature of my Business Relationships

Compensation

Conflict of Interest

I take the potential of a conflict of interest very seriously. I will notify you verbally and through a separate written disclosure if there is a potential or real conflict of interest of which I become aware. My overall recommendations are unbiased and, where possible, are based on an independent survey of companies which provide the products the client is interested in.

Other Business Activity

Client's Right to Ask for More Information

If you would like further information about my qualifications or business relationships, please contact me and I will be happy to help.

Client Acknowledgment

I have read and understand the implications of this disclosure, including any conflict of interest or potential conflict of interest associated with the advisor in relation to any recommendations made.

I agree to continue discussions with you and understand that I may ask for further information regarding this disclosure.

Client
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Advisor
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