WellSense Contract Request

Form Name

WellSense Contract Request

Agent/Agency Type *

NEW to GarityAdvantage - Requesting first contract EXISTING - Adding WellSense to contract portfolio

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 LEGAL Name *

First Name Last Name

Agent NPN *

National Producer Number

NOTE: WellSense REQUIRES your name on this form match your legal name on your state license. Please take care to complete the form correctly. Example: Joseph (Correct!) vs Joe (Incorrect!)

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 *

WellSense (NH)

Notes/Additional Information:

Form completed by: *

First Name Last Name

Contact us with any questions: 800-234-9488