New Agent Request to Join The Team

Welcome to The Team! What types of contracts would you like?
(MEDICARE) Is this your first time requesting Medicare contracts with Expert Insurance Team and Premier Marketing?
Have you completed your AHIP?
Please select the MEDICARE carrier(s) you want to get contracted with? (If you are unsure which to choose, our core 6 carriers are; Aetna, Cigna Healthsprings, Devoted, Humana, United Healthcare, and Wellcare) *
Please list all Medicare Supplement companies or any additional carriers you need that are not listed.
Have you completed your FFM/ACA Certification?
Please select the ACA/Under-65 carrier(s) you want to get contracted with? If you are unsure which to choose, our core 6 carriers are; Ambetter, Bright Health, CIgna, United Healthcare, United HealthONE (STM), and National General(STM) *
Any additional carriers you need that are not listed?
Who referred you? This person will get credit for introducing you to us.
Referral's name
AGENT INFORMATION

** YOUR INFORMATION **
Agent Name

First NameLast Name
Date of Birth

MonthDayYear
Agent NPN
Gender
Social Security Number (Required to complete onboarding. Note this is a secure site)
numeric only
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Email Address
example@example.com
Preferred Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
How will we set up your contracts? Are you a...
Title
AGENCY INFORMATION
Your Agency Name
Your Agency NPN
Your Agency EIN
Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select states you are currently licensed in
Scan Health Plans only Available in CA, AZ, NV, TX. Where would you like to be appointed?
Upload California Insurance License

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Upload Arizona Insurance License

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Upload Nevada Insurance License

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Upload Texas Insurance License

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What is your commission level? It is usually "Agent/Street" level unless discussed differently with your recruiter/upline)
Who is your Immediate Upline/Agency (This is usually the person that referred you to Expert Insurance Team)
W9 Info
Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
Business name/disregarded entity name, if different from above.
Check appropriate box for federal tax classification; check only one of the following boxes.
If Limited liability company, enter the tax classification (C=C corporation, S=S corporation, P=partnership) Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.
W-9 Address (number, street, and apt. or suite no.
W-9 City, state, and ZIP code
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number SSN However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number EIN If you do not have a number, see How to get a TIN on page 3.
Social Security Number
Employer Identification Number
EFT and Direct Deposit Information

Some commissions and bonuses are paid out by Expert Insurance Team or Premier Marketing
Bank Name, City and State where bank is located
Bank Account Number
Bank Account Routing Number
Upload copy of voided check
Voided Check

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Upload Errors and Omissions (E&O) Insurance certificate
Errors and Omissions (E&O) Insurance Certificate

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Today's Date

MonthDayYear
Today's date
Signature
When you click SUBMIT below you have previewed the document and reviewed it for accuracy and this completed request form will be sent to support@expertinsuranceteam.com for processing. If you have any questions, please contact Expert Insurance Team offices at 800-808-0209.
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AGENT INFORMATION

AGENCY INFORMATION

W9 Info

EFT and Direct Deposit Information