• New Producer Contracting

    Buffalo Health Advisors
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  • Demographics

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    Terms of Service

  • Are you doing business as an agency or a corporation?*

  • Legal Questions for Contracting and Appointment Requests

  • Have you ever been charged or convicted of or plead guilty or no contest to any Felony,Misdemeanor, federal/state insurance and/or securities or investments regulations or statutes?Have you ever been on probation?*
  • Have you ever been convicted of or plead guilty or no contest to any Felony?*
  • Have you ever been convicted of or plead guilty or no contest to any Misdemeanor?*
  • Have you ever been convicted of or plead guilty or no contest to a violation of federal or stat securities or investment related regulations?*
  • Has any foreign government, court, regulatory agency, or exchange ever entered an orde against you related to investments or fraud?*
  • Have you ever been charged with a Felony?*
  • Have you ever been charged with a Misdemeanor?*
  • Have you ever been on probation?*
  • Have you ever been or are you currently being investigated, have any pending indictment, lawsuits, or have you ever been in a lawsuit with an insurance company?*
  • Are you currently under investigation by any legal or regulatory authority?*
  • Have you been under investigation by any insurance company?*
  • Have you ever been or are you currently involved in any pending indictments, lawsuits, civi judgments or other legal proceedings (civil or criminal)(you may omit family court).*
  • Have you ever been named as a defendant or codefendant in a lawsuit, or have you ever sue or been sued by an insurance company?*
  • Have you ever been alleged to have engaged in any fraud?*
  • Have you ever been found to have engaged in any fraud?*
  • Has any insurance or financial services company or broker-dealer terminated your contract or appointment or permitted you to resign for reason other than lack of sales?*
  • Were you fired because you were accused of violating insurance or investment relate statures, regulations, rules or industry standards of conduct?*
  • Were you fired because you were accused of fraud or the wrongful taking of property?*
  • Failure to supervise in connection with insurance or investment related statues, regulations, rules or industry standards of conduct?*
  • Have you ever had an appointment with any insurance company denied or terminated for cause?*
  • Does any insurer, insured, or other person claim any commission chargeback or other indebtedness from you as a result of any insurance transactions or business?*
  • Has any lawsuit or claim ever been made against you, your surety company, or errors and omissions insurer arising out of your sales or practices, or, have you been refused surety bonding or E&O coverage?*
  • Has a bonding or surety company ever denied, paid on or revoked a bond for you?*
  • Has any Errors & Omissions (E&O) carrier ever denied, paid claims on or cancelled you coverage?*
  • Have you ever had an insurance or securities license denied, suspended, cancelled or revoked?*
  • Has any state or federal regulatory body found you to have been a cause of an investment – or insurance – related business ess having its authorization to do business denied, suspended, revoked, or restricted?*
  • Has any state or federal regulatory agency revoked or suspended your license as an attorney, a question accountant, or federal contractor?*
  • Has any state or federal regulatory agency found you to have made a false statement or omission or been dishonest, unfair, or unethical?*
  • Have you had any interruptions in licensing?*
  • Has any state, federal or self-regulatory agency filed a complaint against you, fined, sanctioned, censured, penalized or otherwise disciplined you for a violation of their regulations or state or federal statutes?*
  • Has any regulatory body ever sanctioned, censured, penalized or otherwise disciplined you?*
  • Has any state, federal, or self-regulatory agency filed a complaint against you, fined o sanctioned you?*
  • Have you ever been the subject of a consumer initiated complaint?*
  • Have you personally or any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or declared bankruptcy?*
  • Have you personally filed a bankruptcy petition or declared bankrtuptcy?*
  • Has any insurance or securities brokerage firm with whom you have been associated filed bankruptcy petition or been declared bankrupt either during your association or within five years after termination of such association?*
  • Is the bankruptcy pending?*
  • Are there any unsatisfied judgments, garnishments or liens against you?*
  • Are you connected in any way with a bank, savings & loan association, or other lending or financial institution?*
  • Have you ever used any other names or aliases?*
  • Do you have any unresolved matters pending with the Internal Revenue Service or other taxing authority?*
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  • Carrier Appointment Requests

  • Medicare Adcantage & Prescription Drug Plans

  • Aetna
  • Anthem/Amerigroup
  • Blue Cross Blue Shield of TN
  • Cigna
  • Devoted
  • Humana
  • Florida Blue
  • Mutual of Omaha
  • United Healthcare
  • Wellcare

  • Stand Alone Medicare Supplements

  • Aetna Senior Supplemental
  • Cigna Supplemental
  • Mutual of Omaha
  • National General

  • * Please note that Anthem/Amerigroup, Humana, and United Healthcare have dual contracts for Medicare Advantage and Medicare Supplements, so a single appointment will cover both lines.

  • Ancillary & Stand Alone Dental Plan

  • Ameritas
  • Delta Dental of TN
  • GTL

  • Individual/ Family Plans (IFP/ACA)

    Major Medical Short-Term

  • AmBetter
  • Ascension Personalized Care
  • Cigna
  • United Healthcare
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  • Direct Deposit Authorization

    I hereby authorize Buffalo Insurance Group, LLC, hereinafter called COMPANY, to initiate credit entries (and correcting debit entries) to my account indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to credit (or correcting debit) the same to such account.
  • Type of Account*
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