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Application for a Franchise


  • DD dash MM dash YYYY


  • Note: Please note that if you are currently employed by an All Nevada Insurance Agency | ANI Agency, you will be required to disclose your interest to purchase your own ANI franchise to your current employer.
  • Previous business experience (List most recent first.)




  • Perticulars

  • Amount

  • Please provide details on the following asset verification schedules (schedule numbers in parentheses).

  • Assets

  • Amount

  • Liabilities

  • Amount


    (1) Listed securities, bonds/debentures

  • No. Shares

  • Description

  • Pledged (yes/no)

  • Current mkt. value

  • (2) Notes/accounts/mortgages receivable

  • Debtor

  • Relation to applicant

  • Nature of debt

  • Maturity date

  • Original face value

  • Monthly payment

  • Present balance

  • (3) Loans/notes/accounts/bills payable (excluding mortgages)

  • Lender

  • Relation to applicant

  • Nature of debt

  • Secured yes/no

  • Maturity date

  • Original face value

  • Monthly payment

  • Interest Rate

  • Present balance

  • (4) Other Assets
    (e.g., stock options, cash value of life insurance, automobiles and other personal property, etc.)

  • Description

  • Current fair market value

  • (5) Other debts and liabilities
    (e.g., insurance loans, alimony, child support, leases, contracts, legal claims, judgments, chattel mortgages, taxes, comaker or guarantor, etc.)

  • Obligee

  • Description

  • Amount

  • (6) Real estate
    (e.g., insurance loans, alimony, child support, leases, contracts, legal claims, judgments, chattel mortgages, taxes, comaker or guarantor, etc.)

  • Address and description of property (residential, rental, vacant)

  • Date acquired

  • Title in name(s) of

  • Original Cost

  • Original mortgage Amount

  • Mo. payments (incl. taxes,assessments

  • Current market value

  • Current mortgage balance

  • Net Value

  • (7) Business Interests

  • Name and address of business

  • Description

  • Type (Partner, Corp, Sole)

  • Name of All Owners

  • Relation to Applicant

  • Percent Equity

  • Buy/Sell Agreement Yes/No

  • Valuation Method

  • Net Value your interest


  • Personal references (other than employers or relatives)

  • Confidential

    This application does not obligate either party in any manner.

    I submit the following information as my complete and true personal and financial condition as of the date shown below. In accordance with the Privacy Act (5 U.S.C. 552a) and the Freedom of Information Act, I expressly authorize any past or present employer, any law enforcement agency, federal, state or local, or any person who has personal knowledge of my character, work experience or criminal records to release this information to All Nevada Insurance’s Inc. (“All Nevada Insurance’s”). I understand and acknowledge that, as a condition of being considered for the All Nevada Insurance’s franchisee training program, I must submit to a credit history check and criminal background check to be performed by a third party entity of All Nevada Insurance’s choice. I understand All Nevada Insurance may use those results of the credit history and criminal background check in determining whether I will be placed into the franchisee training program or remain in All Nevada Insurance’s franchisee training program. If requested by All Nevada Insurance, I agree to supply statements from my professional advisors (i.e., banker, broker, accountant or attorney) verifying the above assets, and I also agree to furnish copies of federal income tax returns as filed for the last five years. I understand that All Nevada Insurance is relying upon all the above information as a material factor in considering my application to become a All Nevada Insurance’s franchisee, and I therefore agree to promptly notify All Nevada Insurance of any material change in any of the above information or any subsequent information provided to All Nevada Insurance. In addition, I release all persons from liability as a result of true, accurate information. I also certify that neither I nor any of my funding sources is, or has ever been, a terrorist or suspected terrorist, or a person or entity described in Section 1 of U.S. Executive Order 13224, issued September 23, 2001, as such persons and entities are further described at the Internet website I agree to comply with and/or to assist All Nevada Insurance to the fullest extent possible in All Nevada Insurance’s efforts to comply with the above Executive Order.

Disclaimer: This information is not intended as an offer to sell, or the solicitation of an offer to buy, a franchise. It is for informational purposes only. We will not offer you a franchise unless we have complied with applicable pre-sale registration and disclosure documents in your state. Currently, the following states regulate the offer and sale of franchises: California, Hawaii, Illinois, Indiana, Maryland, Michigan, Minnesota, New York, North Dakota, Rhode Island, South Dakota, Virginia, Washington, and Wisconsin. Within the U.S.A., we offer franchises solely by means of our Franchise Disclosure Document (FDD). There are also countries outside the U.S.A. that have laws governing the offer and sale of franchises. If you are a resident of one of these states or countries, we will not offer you a franchise unless and until we have complied with pre-sale registration and disclosure requirements that apply in your jurisdiction.

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