Medicare contracts under Family Financial Solutions Group, Inc
If you have any questions, please call (630) 398-3329.
Name
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First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
E-mail
*
example@example.com
NPN #
*
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
I would like these MA/MAPD/PDP contracts with FFSG
Aetna
AmeriGroup (Anthem business in some states)
Anthem/Elevance/Simply Healthcare
BCBS AZ
BCBS IL
BCBS KC
BCBS MN
BCBS NE
BCBS TN
BCBS TX
Centene (Wellcare)
Cigna
Clear Spring (IL, GA, CO)
Devoted
Essence (IL, IN, OH, MO, KY)
Florida Blue
Freedom Health – Optimum Healthcare
Health First FL
HealthPartners (MN, WI, ND, SD)
HealthPartners/UnityPoint Health (IL, IA)
Humana
Medica/Dean
Molina
Quartz (WI, MN, IA)
UCare (MN)
UHC
Zing (IL, IN, MI)
I would like these Medicare Supplement/Ancillary contracts with FFSG
ACE
Aetna
AFLAC
Allstate
Anthem
BCBS IL
BCBS MN
BCBS NC
BCBS NE
Cigna
Elips
GTL
Heartland
HealthPartners (MN, WI, ND, SD)
Humana
Manhattan Life
Medico (Wellable)
Mutual of Omaha
Oscar
Physicians Mutual
Prosperity Life
UCare (MN)
United American
Woodmen
WPS
ACA/Ancillary
Aetna (Indv/Family)
Ambetter
Ameritas (Dental)
Anthem ACA
BCBS MN
Cigna (Indv/Family)
Health First FL
HealthPartners (MN, WI, ND, SD)
IMG (Travel Insurance)
Medica/Dean (ACA)
Molina (ACA)
NCD (Dental)
Oscar (Indv/Family)
Physicians Mutual (Dental)
Quartz (WI, MN, IA, IL)
UCare (MN)
UnitedHealthcare The Chesapeake Life (Ancillary)
United One UHC (ACA)
Name of Company if it is Lic.
Company NPN
Company FEIN #
Assignment of Commissions, only if your company has a NPN Assignor is the agent name Assignee is the corporation Name assignor and assignee needs to be signed
Upload Assignment of Commissions form if your company has a NPN
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List of States you want to be contracted in.
All W-9 submissions must be the attached (Rev. 3-2024) version. You can find the version in the lower right corner of the 1st page.
W-9 Upload - PDF Only
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E&O Upload - PDF Only
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All State Licenses - PDFs Only
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VOID Check Upload - PDF Only
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Signature
I agree that these contracts will be with Family Financial Solutions Group, Inc.
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