Franchise Information

The filling 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

*Where did you hear about the LA INSURANCE® franchise?


First Name


Last Name


Country of Citizenship


Date of Birth


Tax ID / Social Security Number


Gender:


Are you currently involved with any other insurance affiliated business? If so explain.


What other business or business's are you affiliated with?


Have you ever been convicted of a felony?


If you answered yes to a felony conviction, please explain


Have you ever been associated directly or indirectly with terrorist activity?


Have you ever been involved in any litigation proceeding within the last 5 years?
(If yes, additional information will be required at the time of sale)

Home Telephone


Fax Number


Mobile


Residence Address


City


State


Zip/Postal Code


Country


Email Address

Spouse Personal Information (Use A Separate Application for Partners)

First Name


Last Name


Country of Citizenship


Date of Birth


Tax ID / Social Security Number


Gender:


Have you ever been convicted of a felony?


Have you ever been associated directly or indirectly with terrorist activity?


Have you ever been involved in any litigation proceeding within the last 5 years?
(If yes, additional information will be required at the time of sale)

Educational Background

Highest Level of Eduction


School Attended


Years Attended


GPA


Degree Attained

Business Information

Self Employed


Employed By


No. of Years


Nature of Business


Title


Telephone


Street Address


City


State


Zip/Postal Code


Country


May we contact you at work?

Financial Information (Please List Figures in US Dollars)

Yearly Income from Current Occupation


Yearly Income from Other Sources


Please Explain Other Income


Personal Bank


Individual Liquid Assets (Cash, Stocks, etc.)


Individual Fixed Assets (Home, Car, etc.)


Individual Total Assets


Individual Liabilities (Mortgages, Loans, etc.)


Your Individual Total Net Worth


Would this business be your sole income?

References (Excluding Relatives)

Name


Address


Telephone


Name


Address


Telephone


Partners (All partners should fill out a separate Application)

* Will you have a partner(s)? If not, you may skip this section.


Name


Partner Type


% Ownership


Gender

To include a partner's financial information, ensure they complete a separate application for additional information.

Office Operations

If qualified, when will you invest in a franchise?


How involved will you be in operating the franchise?


Preferred Geographic Franchise Area
1st Pref


2nd Pref


Estimated Training Date Should You Choose to Invest

Disclaimer

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.

I have read the above disclaimer.


Contact

L.A. Insurance Agency
Corporate Headquarters
21745 W 8 Mile Rd.
Detroit, MI 48219

Franchise Info

Agents: Buy Supplies at the L.A. Insurance Store


POLICIES AVAILABLE SAME DAY OVER THE PHONE!