Producer Information Form

Producer Information Form

Medicare Insurance Carrier Contracting Requests
Thank you for your interest in aligning your Medicare insurance carrier contracts with Hilb Group Medicare.

Please complete the form below and be sure to select the Medicare insurance companies you would like to be appointed with.

If you have any questions about how to complete the form, please call Breanna Whorton at (401) 773-7033, or email contracting@hilbmedicare.com.

We appreciate you and we look forward to supporting you in growing your Medicare business!
New/Existing Agent
I am requesting to be appointed as an:
Name (as it appears on your license)

First NameLast Name
Preferred / Nick Name
Date of Birth

MonthDayYear
Date
National Producer Number (NPN)
- Agency Name:
- Agency NPN:
- Agency Tax ID:
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Carrier Selections
- Aetna/Silverscript:
- Anthem/Empire:
- Social Security Number - Required by Anthem
- Humana:
- UnitedHealthcare:
- WellCare:
- Appointment State(s):
  Select multiple states by holding down the CTRL button on your computer and selecting the desired states with your mouse.
- License(s)
  
  Cancelof
- Have you completed AHIP for the current year?
- AHIP Certificate
  
  Cancelof
- Notes - For any general notes for Contracting
- General Agent/Direct Upline
- Name of Person Completing Form
  
  First NameLast Name
- Should be Empty:

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