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 contractEXISTING - Additional contract request
Appointment Type*

IndividualCorporation (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 NameLast 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 CodePhone Number
Primary Address*

Street Address

Street Address Line 2

CityState / 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/SilverscriptAnthemCarePartners of ConnecticutCigna HealthSpring (MAPD only - PDP not available)Commonwealth Care Alliance (CCA)ConnecticareDevoted HealthHealthFirstHumanaWellCareUnited AmericanUnitedHealthcare® Medicare Solutions
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)*

CaliforniaConnecticutFloridaIndianaNew JerseyNew YorkTexasVirginia
UHC Appointment States*

CaliforniaConnecticutFloridaMassachusettsNew JerseyNew YorkNorth CarolinaPennsylvaniaRhode IslandSouth CarolinaTexasVirginiaWest Virginia
Notes/Additional Information:
Form completed by:*

First NameLast 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*

MonthDayYear
Date
For GarityAdvantage Use Only
Garity Approved by
Garity Approval Date

MonthDayYear
Date
Garity Notes:
Should be Empty: