Medicare contracts under Family Financial Solutions Group, Inc
If you have any questions, please call (630) 398-3329.
RSM
Please Select
FFSG
Melinda McNett
Mike Sorensen
Kevin Welch
Jay Ramirez
Name (As shown on your Insurance License)
*
First Name
Middle Name or Initial
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
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 KS (State)
BCBS MI
BCBS MN
BCBS MT
BCBS NC
BCBS NE
BCBS NM
BCBS OK
BCBS TN
BCBS TX
Centene (Wellcare)
Cigna
Clear Spring (CO, GA, IL, NC)
Devoted
Essence (IL, IN, KY, MO, OH)
Florida Blue
Freedom Health – Optimum Healthcare
HAP (MI)
Health First FL
HealthPartners (IA, IL, MN, ND, SD, WI)
Humana
Medica/Dean
Molina
Priority Health (MI)
Quartz (IA, MN, WI)
UCare (MN)
UHC
Zing (IL, IN, MI, OH, TN)
I would like these Medicare Supplement/Ancillary contracts with FFSG:
ACE
Aetna
AFLAC
Allstate
Anthem
BCBS IL
BCBS MN
BCBS MT
BCBS NC
BCBS NE
BCBS NM
BCBS OK
BCBS TX
CIGNA Med Supp
Elips
GTL
HealthPartners (MN, ND, SD, WI)
Heartland
Humana
Manhattan Life
Medico (Wellable)
Mutual of Omaha
Oscar
Physicians Mutual
Prosperity Life
UCare (MN)
United American
Woodmen
WPS (WI)
ACA/Ancillary
Aetna (Indv/Family)
Ambetter (ACA)
Ameritas (Dental)
Anthem ACA
BCBS IL-NM-OK-TX-MT (ACA)
BCBS MN
Cigna (Indv/Family)
Health First FL
HealthPartners (MN, ND, SD, WI)
IMG (Travel Insurance)
Medica/Dean (ACA)
Molina (ACA)
NCD (Dental)
Oscar (Indv/Family)
Physicians Mutual (Dental)
Quartz (IA, IL, MN, WI)
UCare (MN)
United One UHC (ACA)
UnitedHealthOne – Golden Rule
Name of Company (if it is licensed)
As Listed on the License
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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States you want to be contracted in
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Hold the Ctrl Key down to select multiple states
List of States you want to be contracted in.
*
List your resident state first.
I understand that if this is the first time I am requesting a contract with FFSG, I must include all requested documents. Failure to do so will result in a delay in the process.
*
Yes
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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You or your company must be listed as the Insured.
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ALL State Licenses - PDFs Only
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Personal and Company, if applicable
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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.
*
Yes
If available, I would like Advance Commissions
*
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