Loyalty Insurance Marketing Group Producer Information Form/Contract Request

Form Name
Producer Information Form/Contract Request
Welcome to the Producer Information Form/Contract Request. In just a few short steps you will be providing Loyalty Insurance Marketing Group with the information we need to get your contracting to you. Once delivered, we will follow up to help you along in the process. Thanks!
Agent/Agency Type *

NEW to Loyalty Insurance Marketing Group - Requesting first contract EXISTING - Additional contract request
Appointment Type *

Individual Corporation (to be selected by Principals Only) Solicitor (LOA to your upline)
Are you the principal? *

Yes (Principal is LOA to Corporation - commission checks made to corporation) No
Agency Name *
Appointment Type Definitions

Individual: Commission paid direct to the agent

Corporation: Agent contracting as an Agency/Corporation and assigning commission to the Agency/Corporation. This selection is for AGENCY PRINCIPALS ONLY

Solicitor (LOA): Agent employed by upline and assigning commission to the upline
Your General Agent/Upline *
"Other" General Agent/Upline Name *
Agent Name *

First Name Last Name
Agent NPN *
National Producer Number
Agency Name *
Agency NPN *
National Producer Number
Preferred Email *
Use the BEST email to reach you for Medicare business.
Preferred Phone Number *

Area Code Phone Number
Primary Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Carrier Contract Request Selection

NOTE: Not all carriers are available in all states.
Tip! We suggesting starting with a maximum of 5 contract requests. Once you have completed and submitted those contracts, return to this form to request more.
Carrier Contract Request

Aetna/Silverscript Anthem CarePartners of Connecticut Cigna HealthSpring (MAPD only - PDP not available) Commonwealth Care Alliance (CCA) Humana UnitedHealthcare® Medicare Solutions WellCare
Aetna/SilverScript:

Select if transferring Existing contract with Carrier to Loyalty Insurance Marketing Group
Anthem/Empire:

Select if transferring Existing contract with Carrier to Loyalty Insurance Marketing Group
NOTE: Cigna HealthSpring contract for MAPD only. PDP is not available: Contact your upline for more details.
Humana:

Select if transferring Existing contract with Carrier to Loyalty Insurance Marketing Group
UnitedHealthcare® Medicare Solutions:

Select if transferring Existing contract with Carrier to Loyalty Insurance Marketing Group
WellCare:

Select if transferring Existing contract with Carrier to Loyalty Insurance Marketing Group
State for Cigna MAPD Appointment *
Download and Review Anthem Appointment Fees
Anthem Appointment State(s) *

California Connecticut Florida New Jersey New York Texas Virginia
UHC Appointment States *

California Connecticut Florida Massachusetts New Jersey New York North Carolina Pennsylvania Rhode Island South Carolina Texas Virginia West Virginia
Notes/Additional Information:
Form completed by: *

First Name Last Name
NOTE: Anthem requires your Social Security Number to initiate the contract. A member of our Onboarding Team will call you to obtain in order to send the contract invitation. You may also call us directly at (860) 216-0484.
Contact us with any questions: (860) 216-0484
For Loyalty Insurance Marketing Group Use Only
Contract Level *
General Agent/Upline *
Comments/Questions:
Approved by *
Approval Date *

Month Day Year
Date
For GarityAdvantage Use Only
Garity Approved by
Garity Approval Date

Month Day Year
Date
Garity Notes:
Should be Empty: