The filing of this form does not obligate the applicant to purchase or the franchisor to sell a franchise. Complete in full and do not use abbreviations.
Your Personal Information
Spouse Personal Information (Use A Separate Application for Partners)
Financial Information (Please List Figures in US Dollars)
References (Excluding Relatives)
Partners (All partners should fill out a separate Application)
To include a partner's financial information, ensure they complete a separate application for additional information.
This website is not an offer to sell a franchise to, and is not directed to, any resident of a state requiring the filing or registration of franchises unless the Franchisor is registered to sell franchises in that state and has received approval of this website as franchise advertising, if required in that state. The states requiring registration or filing of franchises include: California, Hawaii, Illinois, Indiana, Maryland, Minnesota, New York, North Dakota, Rhode Island, South Dakota, Virginia, Washington and Wisconsin. No franchises will be offered or sold by the Franchisor in any of these states until the franchise offering has been registered and declared effective in that state and the Uniform Franchise Offering Circular required by that state has been delivered to the purchaser before the sale and in compliance with applicable state and federal laws regulating the sale of franchises.
I understand that the granting of a franchise is at the sole discretion of the Franchisor (LA
Insurance Agency® Franchise LLC) I understand that any information I receive from the
Franchisor or from any employee, agent or franchisee of the Franchisor is highly confidential
(“Confidential Information”), has been developed with a great deal of effort and expense to the
Franchisor, and is being made available to me solely because of this Application. I agree that I
shall treat and maintain all Confidential Information as confidential, and I shall not, at any time,
without the express written consent of the board of directors of the Franchisor, disclose, publish,
or divulge any Confidential Information to any person, firm, corporation or other entity, or use any
Confidential Information, directly or indirectly, for my own benefit or the benefit of any person,
firm, corporation or other entity, other than for the benefit of the Franchisor.
I authorize the procurement of an investigative consumer report, a general background search and
an investigation in accordance with anti-terrorism legislation, such as the USA Patriot Act and
Executive Order 13224 enacted by the US Government (collectively referred to as
"Investigations"). I understand that these Investigations may reveal information about my
background, character, general reputation, mode of living, association with other individuals or
entities, creditworthiness, litigation history and job performance. I understand that, upon written
request, within a reasonable period of time, I am entitled to additional information concerning the
nature and scope of these Investigations. I hereby release a representative of the Franchisor, a
credit bureau, security consultant or other investigative service provider selected by the
Franchisor, its officers, agents, employees, and/or servants from any liability arising from the
preparation of these Investigations.
This authorization for release of information includes but is not limited to matters of opinion
relating to my character, ability, reputation, association with others and past performance. I
authorize all persons, schools, companies, corporations, credit bureaus, law enforcement agencies
or other investigative service providers to release such information without restriction or
qualification to a representative of the Franchisor, a credit bureau, security consultant or other
investigative service provider selected by the Franchisor and any of its officers, agents, employees
and/or servants. I voluntarily waive all recourse and release them from liability for complying with
this authorization. This authorization/release shall apply to this as well as any future request for
these Investigations by the above named individuals or entities. I authorize that a photocopy or
facsimile of this release be considered as valid as the original.
I agree that I will settle any and all previously unasserted claims, disputes or controversies arising
out of or relating to my application or candidacy for the grant of a LA Insurance® franchise from
Franchisor, exclusively by final and binding arbitration at a hearing to be administered by a neutral
arbitrator in accordance with the Commercial Rules of the American Arbitration Association and
to be held at Bridgeport, Connecticut, USA, unless my local laws require otherwise. Such claims
include, but are not limited to, claims under federal, state, provincial or common law, such as
employment law, civil rights law, contract law and tort law.
Everything that I have stated in this application is true and I understand that the information
provided by me will be relied upon by the Franchisor. In accordance with anti-terrorist legislation,
I understand that I will not be approved to purchase a franchise if I have ever been a suspected
terrorist or associated directly or indirectly with terrorist activities. I read, understand, and agree to
all of the above. Additionally, I understand that the Franchisor may require me to pass a
standardized Math and English exam, unless I fall under one of the exemptions set forth in the
Franchisor's Offering Circular.
L.A. Insurance AgencyCorporate Headquarters21745 W 8 Mile Rd.Detroit, MI 48219