Please enter the following information in order to complete your registration:
Agent Number
Agent Date of Birth
Agent Tax ID / Agent SSN ( Note: Do not include hyphens/dashes. If your General Agency is established as a corporation, use the corporation tax identification number. Always use the tax identification number that we use for your federal tax form 1099. )
Email Address:
Re-Enter Email address: ( Your email address entered here must match the email address recorded at Lafayette Life. Contact Lafayette Life's Sales Development Center at 1-866-937-5542 for confirmation. )
Question 1: What was your childhood nickname? What is the first name of your favorite childhood friend? What is the middle name of your oldest child? What is your oldest sibling's middle name? What is your oldest cousin's first and last name? What is your oldest cousin's first name? What is the first name of the boy or girl that you first kissed? What was the last name of your third grade teacher? What is your maternal grandmother's maiden name? What is your spouse's mother's maiden name? What is the last name of your favorite childhood teacher? What is your grandmother's first name? What is your mother's middle name? What is the last name of your favorite high school teacher? Answer 1:
Question 2: When was your wedding? What was the date of your parent's wedding? When was your father born? When was your mother born? What was the date of your first child's birth? What was the date of your second child's birth? What date was your oldest sibling born on? Answer 2:
Question 3: What was the name of your first pet? What is the nickname of your spouse? What was your dream job as a child? What was your high school mascot? What was the color of your first car? What was the name of your first stuffed animal? What is the name of a college you applied to but didn't attend? What was the name of your elementary / primary school? What is the name of the company of your first job? What is the name of your grandmother's dog? What is the name of the first school you attended? Answer 3:
User Name: Note: Usernames must be at least 6 characters long.
Password:
Re-Enter password: Note Your password must: Be between 8-64 characters Be different than previous passwords Contain at least one UPPERCASE letter Contain at least one lowercase letter Contain at least one number Contain at least one of the following permitted special characters Special Characters space !exclamation mark "quote (double) #hash $dollar sign %percent &ersand 'quote (single) (parenthesis (open) )parenthesis (close) *asterisk +plus ,comma -dash /slash (forward) :colon ;semicolon <less than =equals >greater than ?question mark @at sign [bracket (open) \slash (back) ]bracket (close) ^carrot _underscore `accent {brace (open) |vertical line }brace (close) ~tilde Randomize your sequence of numbers, and special characters as much as possible. The more randomized your password, the stronger it will be. Avoid numeric sequences (e.g., 6789) and single repeating numbers/letters (e.g., 333 or QQQQ). Avoid using your Social Security Number, date of birth, policy/contract numbers, proper names, or any other personal identification numbers or significant dates.
Register Cancel
