Contracting
All information provided is protected and compliant with HIPAA requirements.
Are you requesting as
*
Agent
Agency
Are you CURRENTLY appointed under a different upline?
*
Please Select
Yes
No
If you answered "Yes" to the question above, please select the carriers you are appointed with. If you answered "No" to the question above, please select "N/A"
*
Aetna
Alignment
AllWell
Anthem
Atrio
Humana
United Healthcare
Prominence
Scan
Select Health
Cigna
Kaiser
N/A
SKIP IF YOU ARE NOT APPOINTING YOUR AGENCY Please give us details BELOW IF AGENCY contracting is being requested - Agency Name, Agency EIN/Tax ID, Agency address, and Agency NPN (IMPORTANT: IF INFORMATION IS MISSING YOUR AGENCY CANNOT BE REQUESTED)
Name
*
First Name
Last Name
Gender
*
Female
Male
SSN
*
Date Of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Email For Contracting
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Producer License Number
*
Producer License Copy
*
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Choose a file
Cancel
of
Agency License Copy (THIS IS REQUIRED IF YOU ARE APPOINTING AGENCY, SKIP IF YOU ARE NOT)
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Choose a file
Cancel
of
Drivers License Number
*
Drivers License State
*
NPN
Do you have an E&O?
Yes
No
E&O Copy
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Choose a file
Cancel
of
Have you completed the current AHIP exam?
Please Select
Yes
AHIP copy
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Choose a file
Cancel
of
Medicare Carriers Requested
Aetna
Alignment
WellCare
Anthem
Atrio
Humana
United Healthcare (You can ONLY request appointment with the following states, Alabama, Arizona, California, Colorado, Florida, Georgia, Hawaii, Illinois, Iowa, Louisiana, Michigan, Mississippi, Missouri, Montana, Nevada, New Mexico, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Texas, Utah, Washington and Wisconsin. FEES APPLY FOR EACH STATE)
Prominence
Scan
Select Health
Cigna
Kaiser
Agency Affiliation
*
Alberto Ochoa (SBI)
Arnold Fulmer (Fulmer Ins Group)
Manager Relationship (If applicable)
Please Select
None
Yordanys Diaz
Farrin Pasifakis
Felipe Gutierrez
Georgana Cepeda
Maria Gutierrez
Ivana Lagonell
Shannon Johnson
Michelle Altamirano
Monica Diosa
Alberto Ochoa
Arnold Fulmer
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