Contracting Request Form
Agents Direct to TSS will complete all applicable fields below to request contracting. For Non-Direct Agents, reporting to an Agency Partner, please have the contracting team (not the agent) complete this form to ensure proper set-up. You can reach our Helpful Agent Resource team, H.A.R.T, at: 281-892-0192 or HART@TrustedSeniorSpecialists.Com.
Who is contracting being requested for?
An Agent (Only complete Agent Information Below. Agency Info Not Required)
An Agency (Please complete Agent AND Agency Information Below)
Principal / Agent Name (Must match what is on your license/with NIPR)
*
Mr.
Mrs.
Dr.
Miss
Prefix
First Name
Middle Name
Last Name
Suffix
Agent Email
*
example@example.com
Date of Birth
*
Social Security Number
*
Agent NPN
*
Agent Resident License Number
*
Agency Name (If applicable) (Must contract as a licensed ENTITY if requesting a GA, MGA, or SGA level contract with Cigna Medicare Advantage)
Agency Tax-ID (if applicable)
Agency NPN (if applicable)
Agency Resident License Number (if applicable)
Please select immediate upline from the drop-down menu below.
*
Please Select
Trusted Senior Specialists
A Gaznares Inc- Ana Gaznares
AA Eagle Enterprises
Abel Cortez
Acadiana Medicare Advisors
ADE Insurance Advisors
Advisors Tax Life Health LLC (dba: MedCare East)
Aging and Disability
AHIA-Joe Chetwood
Almauri Insurance-Rosalinda Almanza
Andrew Lillard
Angela Salas
Aspire 54
Association Concepts
Azure Financial Group
Benefit Concepts Inc
Benjamin Winn Inc- Mike Torres
Bergstrom & Bergstrom
Berson Sokol Agency
BFS Management- Mike Boyter
BNR Agency- Bill and Rilla Menchaca
Bodenhamer & Associates
Bold Insurance-Antonio
Boomers Insurance
Boren Insurance Resource Group-Shed Boren
Bridge Brokerage
C and S Insurance Agency
Casey Giron Insurance Agency-Casey Giron
Catalina Ramos LLC (dba: MedCare West)
CCU Holding
CDA Secure Health Solutions
Centerstone Financial
Chastain Agency
Choice Health
Clark and Associates Consultant
Clutch City Insurance-Andrew Cheng
Clyde Richardson
Complete Life and Health-Melissa Slade
Connie Health
Consolidated Senior Care - Rob Tyson
Constellation Insurance Group
Cornerstone Insurance
Coverany Insurance Agency
Cox Financial Solutions
Credible Coverage-Chris Argote
Crowns Brokers Inc- Osmer Martinez
Curiman Brokers Group-Pablo Martinez
Cutting Edge Insurance Consultants
Dap Development
Davila & Associates
Diana Gonzales
Diego Consulting
E&E Insurance Agency
E. Alaniz Insurance Agency
E.D. Logan Enterprises- Ed Logan
Edmundo Hernandez Lara
El Paso Insurance Group-Victor D & Felix H
El Paso Obamacare
Elizabeth Lomas
Elizondo Financial Solutions
Empower Brokerage- Rodney Culp
E-Quality
Esequiel Garcia Insurance Agency
Eureka Insurance Agency
First National Life & Health
Foshee Insurance Agency-Duncan Foshee
Gaitan Insurance, LLC
Gallegos De Lara Insurance & Retirement
Get Covered Insurance Agency
GG Mediplan Consultants
GGC Brokerage Corporation
Gilbert Fonseca
Gilbert Ramos Insurance Advoacates
Giovanny Uribe
Global American Financial
Gloria Hernandez
Golden Age Benefits-Ray Miller & Dennis Mitchell
Golden Plan Choice
Golden Senior Advisors- Cal Hero
Grean Leaf Insurance
Guardian Benefits
Heartland Financial
H&P Insurance & Financial Services
Healthcare Experts
Hoyos Insurance Services LLC
Hughes & Associates
IBC Insurance Agency- Dale Randol
Independent Insurance Specialist - Eric Nichols
Index Insurance
Infinitus LLC-Lisa Trevino
Infinitus Marketing Alliance-Hector Gracia
Informis Health Solutions
Insurance Advisor Inc
Insurance by Faith Agency
Insurance Protection
Invictus Brokerage Group - Ron Chapman
ISAN Insurance Group- Sandra Martinez
J&G Silva Investments & Securities
JBarnum International- Jack Barnum
Jeremy Johnson Agency
Jerry Molina Financial & Insurance Services, LLC
Jesus Alcocer
JG Musgrove Financial
JIMCO Insurance Services
JOLU Gaming Inc
Josephine Lynch
Julibea
Julifs Holdings - Steve Julifs
JWD Insurance Group
King of Medicare
Knight Financial Advisors
Lara Insurance Services
Leading Choice Insurance Agency
Leal Retirement Solutions
Life & Wealth Management Group
Linda Buckholdt
LJP Insurance Consultants - Laquetta Prince
Louisa White McFarland
Lum & Nakano Agency - Michael L & Shawn N
M3 Enterprises
Mar Vel Investments Inc
Marc Burns
McCunis & Fox- Misty Fox
Med Care Plus - Ana Casillas
Med Supp University
Melissa Mitchell
Melograna Financial Group
Mi Familia
ML Benefits Plans
Morales Insurance Agency
More Freedom
MTZ Benefits Group
MVP Life & Health-Diana Montiel
Nations Insurance Solutions - Celia Neyra
Nelly Garcia
Nix Group
On Point Insurance Group
Other: (If your upline is not listed, please enter the upline name in the field below)
Panarama Successful People
Paul Jason Smith
Peek Performance -Clay Peek
Perez Financial Services
Pohler Inc -Theresa Pohler
Policy Direct Insurance Services
Premier Marketing
Primacy Insurance & Financial Services
Prime Fiscal Choice
Prominent Insurance Group
Providers First
PTT Financial - Albert Robledo
Puga Insurance Agency - Noe Puga
Quality Affordable Insurance, Inc
Rafael Martinez Insurance Group
RAj & Associates
Ray Ball Financial Group
RBCU Investments Group
RBMS Health Inc
Rene Herrera
RF Financial Group
RG Insurance Advisors Agency
Richey Insurance Agency
Roumalda Lopez LLC
Sacred Insurance Advisory Group
Secure Earnings Retirement
Senior Care Health Plans
Senior Health Pro - Juan Mendez
Senior Image Incorporated
Senior Medical Benefits - Alex Gonzales
Shaughnna LLC - Shaughnna Blackmon
Sirafi Insurance Services - Ed Sirafi
Sonny Salas Agency - Sonny Salas
Sosa Insurance Agent Advisors
Sound Harbor Financial
South Atlantic Management- Jason Thomason
South Texas Insurance Advisors
Statewide Health Advisors
Sunrise Family Health Benefits
Team Alvarez - Gus Alvarez
The Copeland Group - Mel Copeland
The Insurance Advisor - Jose Sanchez
The Insurance Team
The Koonce Group - Michael Koonce
The Outten Agency
The Win Group
Tidewater Management
Toni Says - Toni King
Total Retirement Solutions - Cayetano Gamboa
Trejo Insurance Group
Trevino & Associates Consulting Firm
Trevino Insurance Advisors
Trevino's Insurance Resource Group
True Health Solutions - Darius Kohanim
Trusted Benefits Group
Trusted Insurance Agency
Trusted Senior Specialists
TST Financial Solutions
TX Agent Group, LLC
Union Insurance Advisors
US Senior Services
Vidafuente LLC
Vital Insurance Group
Why Insurance
Your Retirement Inc
Other: (If your upline is not listed, please enter the upline name in the field below)
If you selected "Other" in the drop-down above, please enter the name of your immediate upline below.
How will the agent be compensated?
*
Please Select
Direct-Paid by Carrier
Indirect - Paid by Upline (AoC)
What is the agent's level? (Production requirements vary by carrier & may apply)
*
Please Select
0-Field-LOA (Agent assigns commissions)
0-Telesales-LOA (Agent assigns commissions)
1-Street (Individual agent/no downline)
2-GA (Minimum 5 agents in downline)
3-MGA (Minimum 10 agents in downline)
4-SGA (Minimum 20 agents in downline)
You may request up to 3 contracts per request form. Please select your 1st carrier from the drop-down menu below.
*
Please Select
Aetna Medicare Advantage
Aetna ACA
Aetna Medicare Supplement
Ace Medicare Supplement
Alignment
AllState Medicare Supplement
Ambetter
American Home Life
Amerigoup
Anthem ACA
Anthem MA
APEX Dental
BCBS ACA (TX Only)
BCBS Medicare (TX Only)
Christus Health ACA
Christus Health Medicare
Cigna IFP (ACA)
Cigna Medicare Advantage
Cigna Medicare Supplement
Columbian Life
Community Health Choice ACA
Community Health Choice Medicare
Central United Life/Manhattan Life
Devoted Health
Foresters
Guarantee Trust Life (GTL)
HMA
Humana ACA
Humana Medicare
Imperial
Kaiser
Kelsey Care Advantage
LSW
Lumico
Manhattan Life Supplement (MAC)
Medico
Memorial Hermann
Molina ACA
Molina MA
Mutual of Omaha Life/Med Supp
Mutual of Omaha PDP (OHIC)
New Era/Philadelphia American
NGL
PHMA
Royal Neighbors
Scott & White Medicare Advantage
Trinity Life
Union Security
United American
United Healthcare-Medicare
Untied Healthcare-ACA
Verda
Wellcare
Please select your 2nd carrier from the drop-down menu below (if applicable)
Please Select
Aetna Medicare Advantage
Aetna ACA
Aetna Medicare Supplement
Ace Medicare Supplement
Alignment
AllState Medicare Supplement
Ambetter
American Home Life
Amerigoup
Anthem ACA
Anthem MA
APEX Dental
BCBS ACA (TX Only)
BCBS Medicare (TX Only)
Christus Health ACA
Christus Health Medicare
Cigna IFP (ACA)
Cigna Medicare Advantage
Cigna Medicare Supplement
Columbian Life
Community Health Choice ACA
Community Health Choice Medicare
Central United Life/Manhattan Life
Devoted Health
Foresters
Guarantee Trust Life (GTL)
HMA
Humana ACA
Humana Medicare
Imperial
Kaiser
Kelsey Care Advantage
LSW
Lumico
Manhattan Life Supplement (MAC)
Medico
Memorial Hermann
Molina ACA
Molina MA
Mutual of Omaha Life/Med Supp
Mutual of Omaha PDP (OHIC)
New Era/Philadelphia American
NGL
PHMA
Royal Neighbors
Scott & White Medicare Advantage
Trinity Life
Union Security
United American
United Healthcare-Medicare
Untied Healthcare-ACA
Verda
Wellcare
Please select your 3rd carrier from the drop-down menu below (if applicable)
Please Select
Aetna Medicare Advantage
Aetna ACA
Aetna Medicare Supplement
Ace Medicare Supplement
Alignment
AllState Medicare Supplement
Ambetter
American Home Life
Amerigoup
Anthem ACA
Anthem MA
APEX Dental
BCBS ACA (TX Only)
BCBS Medicare (TX Only)
Christus Health ACA
Christus Health Medicare
Cigna IFP (ACA)
Cigna Medicare Advantage
Cigna Medicare Supplement
Columbian Life
Community Health Choice ACA
Community Health Choice Medicare
Central United Life/Manhattan Life
Devoted Health
Foresters
Guarantee Trust Life (GTL)
HMA
Humana ACA
Humana Medicare
Imperial
Kaiser
Kelsey Care Advantage
LSW
Lumico
Manhattan Life Supplement (MAC)
Medico
Memorial Hermann
Molina ACA
Molina MA
Mutual of Omaha Life/Med Supp
Mutual of Omaha PDP (OHIC)
New Era/Philadelphia American
NGL
PHMA
Royal Neighbors
Scott & White Medicare Advantage
Trinity Life
Union Security
United American
United Healthcare-Medicare
Untied Healthcare-ACA
Verda
Wellcare
Upload a Copy of Insurance License, E&O Certificate, AHIP Certificate, Voided Check, and/or Written Explanation for any "Yes" answer on background.
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Notes: Please DO NOT list additional carriers here. Submit a separate request if you need more than one carrier. This section is to add any additional information you feel is important for us to know in the box below. For example: If the agent is already contracted and has a release, if the request is for an internal hierarchy change, level change, or if you would like to request any carrier not listed above, you may add that information here.
Printed Name of the person completing this request form. (This can be the agent, agency partner, or contracting representative, making a request on behalf of a downline agent)
*
First Name
Last Name
Signature of person making this request
*
Submit
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