Contract Form

Who is contracting being requested for?

An Agent (Only complete Angent Information Beloww. Agency Info Not Required)An Agency (Please complete Agent AND Agency Information Below)

Principal / Agent Name (Must match what is on your license/with NIPR)*

PrefixFirst NameMiddle NameLast NameSuffix

Agent Email*

Please Verify The Email

Social Security Number*

Check Twice

Agent NPN*

Check Twice

Agent Resident License Number*

Check Twice

Agency Name (If applicable) (Must contract as a licensed ENTITY if requesting a GA, MGA, or SGA level contract with Cigna Medicare Advantage)

Agency NPN (if applicable)

Agency Tax-ID (if applicable)

Agency Resident License Number (if applicable)

Please select immediate upline from the drop-down menu below.

If you selected "Other" in the drop-down above, please enter the name of your immediate upline below.

How will the agent be compensated?*

You may request up to 3 contracts per request form. Please select your 1st carrier from the drop-down menu below.*

What is the agent's level? (Production requirements vary by carrier & may apply)*

Please select your 2nd carrier from the drop-down menu below (if applicable)*

Please select your 3th carrier from the drop-down menu below (if applicable)*

Upload a Copy of Insurance License, E&O Certificate, AHIP Certificate, Voided Check, and/or Written Explanation for any "Yes" answer on background.

Notes: Please add any additional information you feel is important for us to know in the box below. For example: If the agent is already contracted and has a release, if the request is for an internal hierarchy change, level change, or if you would like to request any carrier not listed above, you may add that information here.

Printed Name of the person completing this request form. (This can be the agent, agency partner, or contracting representative, making a request on behalf of a downline agent)*

First NameLast Name

Signature of person making this request