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
Format: (000) 000-0000.
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
Format: (000) 000-0000.
Fax
Format: (000) 000-0000.
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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Alera Group Medicare

Broker Information

Company Information

Payment Details