Please choose the available companies you would like to be contracted with.

INDIVIDUAL HEALTH CARRIERS *

	Ambetter (Centene) *Subject to Approval	BCBST	Bright Healthcare	Cigna Individual	Molina Healthcare	OSCAR Healthcare	None
Select	Ambetter (Centene) *Subject to Approval	BCBST	Bright Healthcare	Cigna Individual	Molina Healthcare	OSCAR Healthcare	None

MEDICARE CARRIERS *

	Aetna	Cigna Health Springs	Humana	United Healthcare	Wellcare	None
Select	Aetna	Cigna Health Springs	Humana	United Healthcare	Wellcare	None

SUPPLEMENTAL CARRIERS *

	Cigna (Dental Only)	Guardian	Humana (Dental & Vision)	Manhattan Life	Standard Life	Sure Bridge	Teladoc	United HealthOne *One time appointment fee $60	VSP (Vision Only)	None
Select	Cigna (Dental Only)	Guardian	Humana (Dental & Vision)	Manhattan Life	Standard Life	Sure Bridge	Teladoc	United HealthOne *One time appointment fee $60	VSP (Vision Only)	None

Producer Information

Information MUST match Insurance License

First Name *

Last Name *

Social Security #

Date of Birth * +

National Producer Number *

State License #

Email *

Cell *

Residential Address (No P.O. Boxes)

Address *

Apt/Suite

City *

State *

Zip Code *

Non-Resident License

	AL	AR	AZ	CA	FL	GA	IL	IN	LA	MD	MI	MO	MS	NC	NE	OH	OK
.	AL	AR	AZ	CA	FL	GA	IL	IN	LA	MD	MI	MO	MS	NC	NE	OH	OK

	OR	PA	SC	TN	TX	UT	VA
.	OR	PA	SC	TN	TX	UT	VA

Legal Questions for Contracting and Appointment Request

Have you ever been charged, convicted, plead guilty, or no contest to any Felony or Misdemeanor? *

Yes

No

Have you ever been or are you currently being investigated, have any pending indictments, lawsuits, or have you ever been involved in a lawsuit with an insurance company? *

Yes

No

Have you ever had an appointment with any insurance company denied or terminated? *

Yes

No

Has any lawsuit or claim ever been made against your surety company, or errors and omissions insurer, arising out of your sales or practices, or, have you been refused sure bonding or E&O coverage? *

Yes

No

Have you ever had an insurance or securities license denied, suspended, canceled, or revoked? *

Yes

No

Have you personally filed a bankruptcy petition or declared bankruptcy? *

Yes

No

Is the bankruptcy pending? *

Yes

No

Have you ever had any judgments, garnishments or liens against you? *

Yes

No

If you answered YES to any questions, provide an explanation that includes dates, actions, and descriptions. Upload supporting document(s)

I attest that the information I have provided is true to the best of my knowledge. I acknowledge that if any information changes, I will notify my agency office within 5 days of such change. Further, I understand that my agency may contact me when I need to answer carrier specific questions. *

clear

Errors and Omissions E&O *

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Date * +