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
2 digit month, 2 digit day, 4 digit year
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
2 digit month, 2 digit day, 4 digit year
Are you working with a General Agency (GA) or Upline?
If Yes, GA's name
Requested Contracts
Requested Contracts (MAPD)

Other
Requested Contracts (Medicare Supplement)

Other
Which states would you like to appoint?
Select one
Payment Details
Payment Made Payable To:
Must match W-9 information
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.
Should be Empty:

Alera Group Medicare