Agent Contracting Request (ACR)

Thanks for your interest in contracting with PPI. Complete the information in the form below, and our team will reach out to you with contracting instructions.

Questions? Call us at 864.228.2635

NOTE: This form is NOT a contract. This form will indicate your interest in appointing through PPI, and then additional contracting links/paperwork and certifications (if applicable) will be required before you begin marketing/selling any carrier products listed on this form. After completing this form, our team will reach out to you with additional instructions for new appointments and transfers.

Marketer Email

Marketer Email - 2

Marketer Relationship Code

Source

Upline Agency

Direct Upline Manager

UA Code

For L workflow

UA Email

example@example.com

Internal Only: Is this a manager specific ACR?

Internal Only: Is this a program specific ACR?

Internal Only: Is this being completed by a marketer?

Have you completed your FFM (CMS) Certification?

YesNo

Are you licensed in and plan to market ACA in any of the following states? These states operate their own State-based Exchanges: AR, CA, CO, GA, KY, MD, ME, NV, NJ, NM, NY, PA, VA, WA

YesNo

If yes, have you completed the State-Based Exchange certification(s) for the state(s) above that you will market ACA plans in?

YesNo

Note: All agents marketing ACA health plans are required to complete the CMS (FFM) Certification and/or State-Based Exchange Certifications (if appliable).

If you have not completed your FFM (CMS) Certification and/or the State Based Exchange certification(s) yet (if applicable), then you must complete those required certifications before proceeding with ACA carrier contracting.

Click here for more information and instructions for completing the FFM (CMS) Certification.

Click here for more information and instructions for completing the State-Based Exchange Certifications.

Once you have completed your FFM and/or State-Based Certifications, please return to this form to complete your contract requests.

Questions? Call our Agent Care Team at 877-612-7317

Status*

New PPI AgentCurrent PPI Agent

Name (as it appears on your license)*

First NameMiddle NameLast Name

Nickname/Preferred Name

Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code

Mailing Address Type*

ResidenceBusiness

Primary E-mail*

Confirmation Email

Cell Phone Number*

Secondary Phone Number

NPN*

Resident State*

Are you requesting to appoint as an individual or an agency?*

IndividualAgencyBoth Individual and Agency

Agency Name

Agency NPN

Agency/Manager Affiliation*

Enter PPI if you are not working with a specific manager or agency.

Direct Upline Manager

Select the Lines of Insurance that you sell

Individual HealthGroup HealthSenior (Medicare Advantage / Medicare Supplements)Financial / Life Insurance

PPI Level - Level Specific Link

PPI Health Level

PPI Group Level

PPI Senior Level

PPI Ancillary Level

PPI Financial Level

Level Change Instructions

Note here if any of the levels above are CHANGE REQUESTS

Interested in Senior Lead Program?

YesNo

EXPERIENCE: In the past two years, approximately how many apps have you submitted to carriers for these types of products?

	# of apps in the past 2 years
Medicare Supplements
Medicare Advantage
Life
Dental/Vision/Hearing
Cancer

Top 5 Counties for leads (list the state and county for each like ST-County):

Interested in the 12 month Health Sales & Lead Program?

YesNo

Health Agent Experience

How many clients have you sold an "Under 65" health policy to in your career?

How many new "Under 65" health clients did you sell a policy to in the last 12 months?

How many of your new health clients from the last 12 months were Non-ACA plans?

How frequently would you like 15 health leads?

MonthlyBi-WeeklyWeekly

CONTRACT REQUESTS

Click the grey bars below to see all carriers available in that segment. Select the carriers you would like to request appointment with, and our contracting team will send you instructions for new appointments & transfers.

NOTE: Selecting carriers below indicates intent to contract; you will not be fully contracted until you complete all required paperwork/links for each carrier.

Join Our Team!