WellSense Contract Request

Form Name

WellSense Contract Request

Agent/Agency Type*

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

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 LEGAL Name*

First NameLast Name

Agent NPN*

National Producer Number

NH State License*

Must Have NH License

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 CodePhone Number

Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Carrier Contract Request*

WellSense (NH)

Notes/Additional Information:

Form completed by:*

First NameLast Name

Contact us with any questions: 800-234-9488