Broker Information Form

Alera Group Medicare
Are you new to Medicare sales with Alera General Agency?
Broker Information
Agent Name

First NameLast Name
E-mail
Date of Birth

MonthDayYear
Social Security #
(SS or Tax ID will be needed to process your commissions)
Cell Phone
Broker License #
National Producer #
FFM ID
Company Information
Agency Name
Tax ID
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Phone
Fax
Agency Insurance License #
Website Address
Name of E&O Carrier
Effective Date

MonthDayYear
Are you working with a General Agency (GA) or Upline?

YesNo
If Yes, GA's name
Requested Contracts
Requested Contracts (MAPD)

AetnaAllwell / Centene / WellcareAnthemCapital Blue CrossDevoted HealthGeisingerHighmark MedicareHumanaIndependence Blue CrossPeak HealthUnited HealthCareUPMC for LifeOther
Requested Contracts (Medicare Supplement)

ACEAvalonAetnaCignaCompanionHighmarkLumicoMedicoMutual of OmahaTransamericaUnited HealthcareWULAOther
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Payment Details
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If you plan to assign commission to an agency or individual other than yourself, please complete the Compensation Assignment form.

EFT is the only method for commission delivery. You must complete the EFT Form or commissions won’t be remitted.
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Alera Group Medicare

Broker Information

Company Information

Payment Details