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)
Agent Information
*
Agency Information
*
Immediate Upline
*
Carrier Requests
You may select up to 6 carriers that you would like to contract with. If you need to request more than 6 carriers, please submit additional form requests. Do not request additional carriers in the comments/notes section. They will not be processed.
Enter the following information for each carrier you are requesting. Please note that you can only request contracts that the upline (all levels) are already contracted for. Not all levels are available for all carriers and requirements to qualify may also vary.
*
When making your carrier requests above, did you request to contract with Ambetter ACA? If yes, additional Ambetter ACA questions are required and will appear below.
*
Please Select
Yes
No
What is the number of anticipated applications you expect to submit for the current plan year?
*
Are you actively selling with another ACA carrier?
*
Please Select
Yes
No
Are you requesting an ICHRA contract?
*
Please Select
Yes
No
If requesting an ICHRA contract, which states are you requesting? (select all that apply)
*
Arizona
Florida
Georgia
Indiana
Kansas
Missouri
Mississippi
Nebraska
Ohio
Oklahoma
South Carolina
Tennesee
Texas
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.
Upload a Copy of Insurance License, E&O Certificate, AHIP Certificate, Voided Check, and/or Written Explanation for any "Yes" answer on background.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Requestor's Information
*
Signature of person making this request
*
Submit
Should be Empty: