Contracting Request Form

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)*

PrefixFirst NameMiddle NameLast NameSuffix
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.*
If you selected "Other" in the drop-down above, please enter the name of your immediate upline below.
How will the agent be compensated?*
What is the agent's level? (Production requirements vary by carrier & may apply)*
You may request up to 3 contracts per request form. Please select your 1st carrier from the drop-down menu below.*
Please select your 2nd carrier from the drop-down menu below (if applicable)
Please select your 3rd carrier from the drop-down menu below (if applicable)
Upload a Copy of Insurance License, E&O Certificate, AHIP Certificate, Voided Check, and/or Written Explanation for any "Yes" answer on background.

Cancelof
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 NameLast Name
Signature of person making this request*

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