Medicare contracts under Family Financial Solutions Group, Inc
If you have any questions, please call (630) 398-3329.
RSM
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FFSG
Mike Sorensen
Name (As shown on your Insurance License)
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First Name
Middle Name or Initial
Last Name
Preferred Method of Contact
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Phone Call
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Work Address
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Street Address
Street Address Line 2
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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
State
Zip Code
Work Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Work 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:
Rows
I Want This Contract For The First Time
I Want To Move This Contract To FFSG
Current Upline
Aetna
Alignment (AZ, CA, NC, NV, TX)
AmeriGroup (Anthem business in some states)
Anthem/Elevance/Simply Healthcare
Anthem
Aspire Health Plan (CA)
Astiva Health (CA)
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
Blue Shield (CA)
CalOptima Health (OneCare) (CA)
Centene (Wellcare)
Clear Spring (CO, GA, IL, NC)
Clever Care (CA)
Clover Health
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)
HealthSpring (Cigna)
Humana
IIHCP (CA)
Imperial Health (CA)
Indiana University Health Plans
L.A. Care (CA)
Medica/Dean
Molina
myPlace Health (CA)
Providence (CA)
Quartz (IA, MN, WI)
Scan (CA)
SelectHealth (CO, ID, NV, UT)
UCare (MN)
UCLA (CA)
UHC
Welbe Health (CA)
WellCare
Wellpoint (AZ, IA, NJ, TN, TX, WA)
Zing (IL, IN, MI, OH, TN)
I would like these Medicare Supplement/Ancillary contracts with FFSG:
Rows
I Want This Contract For The First Time
I Want To Move This Contract To FFSG
Current Upline
Aetna
AFLAC
Allstate
American Home Life
Anthem
Bankers Fidelity
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
INA
Liberty Bankers
Manhattan Life
Medico (Wellabe)
Mutual of Omaha
Physicians Mutual
UCare (MN)
Woodmen
WPS (WI)
ACA/Ancillary
Rows
I Want This Contract For The First Time
I Want To Move This Contract To FFSG
Current Upline
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)
Humana (Dental & Vision)
IMG (Travel Insurance)
Medica/Dean (ACA)
Molina (ACA - ONBOARDING FREEZE UNTIL 2027)
NCD (Dental)
Oscar (Indv/Family)
Physicians Mutual (Dental)
Quartz (IA, IL, MN, WI)
UCare (MN)
United One UHC (ACA)
UnitedHealthOne – Golden Rule
WPS - Group and Individual (WI)
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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List of States you want to be contracted in.
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List your resident state first.
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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Personal and Company, if applicable
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VOID Check Upload - PDF Only
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I agree that these contracts will be with Family Financial Solutions Group, Inc.
*
Yes
If given the choice, I would like Advance Commissions
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Yes
No
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