COMPANY PROFILEDEFINITION OF TERMS:
INSURANCE COMPANY – A company that manufactures, underwrites, and/or sells insurance products.
BROKER DEALER (USA & Canada only) – A firm that buys and sells securities on its own account or on behalf of its customers.
GENERAL AGENCY (outside the USA/Canada) – A company that has a contractual agreement with one or more insurers to sell theirinsurance products through their direct sales force.
BANCASSURER – A bank that sells insurance products through its own distribution channels.

---------------CERTIFYING OFFICER – This individual will be responsible for certifying production data submitted for MDRT membership; canaccess the list of all current MDRT members affiliated with their company and submit membership applications on-line.
COMPANY ADMINISTRATOR – This individual will be able to access the list of all current MDRT members affiliated with theircompany and submit membership applications on-line.

SUBMIT COMPLETED FORM TO: Companies@mdrt.org

1

Revised June 2021

COMPANY PROFILE
Form Submission Date: ________For Internal MDRT use only:
Company ID#New Company

Update / Information Change

Parent Company (if applicable): ___________________________________________________________
Please SelectCompany Type _________________________________________________(See Page 2 for Definition)

If updating Company Name Please Provide Previous Company name to be updated:_____________________________________________________________
Company Name (required): _______________________________________Company Headquarters Address: ______________________________________________________________________________________________

City: __________________________ State/Province: _________________
Postal Code: _________________
CEO:CEO Name: Select

New

Country: _______________________

Replacement ________________________________________________Name of previous CEO__________________________________________________________________

Email: _____________________________________________________________________________
Address: ___________________________________________________________________________(If different from above)

City: ___________________________________

State/Province: _________________________

Postal Code: ___________________Country: ______________________________

CERTIFYING OFFICER (see Page 1 for Definition):New

Replacement _______________________________Name of previous Certifying Officer

Name: Select _______________________________________________________________________
Position Title: _______________________________________________________________________
Email: _____________________________________________________________________________
Address: ___________________________________________________________________________(If different from above)

City: ___________________________________

State/Province: _________________________

Postal Code: ___________________Country: ______________________________

Phone: ________________________________

Ext. ________

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Revised June 2021

CERTIFYING OFFICER (see Page 1 for Definition):
Name: SelectNew

Replacement _______________________________Name of previous Certifying Officer___________________________________________________________________

Position Title: _______________________________________________________________________
Email: _____________________________________________________________________________
Address: ___________________________________________________________________________(If different from above)

City: ___________________________________

State/Province: _________________________

Postal Code: ___________________Country: ______________________________

Phone: ________________________________

Ext. ________COMPANY ADMINISTRATOR (see Page 1 for Definition):New

Name: SelectReplacement ___________________________Name of previous Company Administrator___________________________________________________________________

Position Title: _______________________________________________________________________
Email: _____________________________________________________________________________
Address: ___________________________________________________________________________(If different from above)

City: ___________________________________

State/Province: _________________________

Postal Code: ____________________________Country: ______________________________Phone: _________________________________

Ext. ________COMPANY ADMINISTRATOR (see Page 1 for Definition):New

Name: SelectReplacement ___________________________Name of previous Company Administrator___________________________________________________________________

Position Title: ______________________________________________________________________
Email: ____________________________________________________________________________
Address: __________________________________________________________________________(If different from above)

City: ___________________________________

State/Province: ________________________

Postal Code: ____________________________Country: _____________________________

Phone: _________________________________

Ext. ________For internal MDRT use only:______ GM entered ____________ Date Entered______ Member Processing entered3____________ Date Entered

Revised June 2021