Agent Onboarding Form

Agent Onboarding Form
Thank you for challenging yourself and taking your first steps to becoming an Independent Agent! After completing this form we can begin getting you contracted with the carriers/products you indicate below.

As an Agency, we offer an opportunity for Independent Field Agents (1099 positions) to receive 100% commission/renewals for Life, Marketplace, Medicare, Medigap, and Ancillary products.

*Commission/Renewals are based on the CMS Agent-Broker Compensation Data for the contract year or an insurance carrier’s Commission Schedule, whichever is applicable.

Agents MUST have an ACTIVE General Lines (Life, Accident, Health and HMO) license in order to join.

For Medicare: Agents must have a current AHIP Certificate.

If you do not have the required items, please contact info@crediblecoverage.com to discuss your options.
Name (must match what is on NIPR/State License)*

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Social Security Number*
Home Address (no P.O. Box)*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Preferred Business Number (if different from above)
Will be registered with insurance carrier(s)
Email*

Confirmation EmailConfirm Email
Preferred Business Email (if different from above)
Will be registered with insurance carrier(s)
Agent National Producer Number (NPN)*
Agent Resident State License Number*
Which 1099 option are you interested in?

100% Commission/Renewals50% Commission/RenewalsNot sure
Would you like a company email ($12.99+tax/month, name@crediblecoverage.com)?

YesNo thanks, I'll use my own
Which products are you interested in offering?*

MedicareAncillary (Individual Dental, Vision, Hearing; Critical Illness; Hospital Indemnity)MarketplaceLife InsuranceAnnuities/IRAsNot Sure

Select the Carriers and Products you would like to be able to offer. Not sure? Text/Email Chris at: 281-305-9335 / chris@crediblecoverage.com.

	New Agent Contract	Transfer with Release
Aetna (MAPD + PDP)
Aetna (Medigap + Life + Ancillary)
American National [ANICO] (Life)
BlueCross BlueShield TX Option (MAPD + PDP + Medigap)
BlueCross BlueShield FL Option (MAPD + Medigap)
Cigna (MAPD + PDP)
Cigna (Medigap + Ancillary)
Devoted Health (MAPD)
Guarantee Trust Life (Ancillary)
Humana (MAPD + PDP + Medigap + Ancillary)
KelseyCare Advantage (MAPD) TX ONLY
Manhattan Life (Medigap + Ancillary)
Memorial Hermann (MAPD) TX ONLY
Molina (MAPD)
New Era / PALIC (Medigap)
Pioneer American (Life)
UnitedHealthcare (MAPD + Medigap)
WellCare (MAPD + PDP)

Please attach a current copy of the following documents: Resident State Insurance License, Errors & Omissions (E&O) Insurance Certificate, AHIP Certificate, W9 (can be found at https://www.irs.gov/pub/irs-pdf/fw9.pdf). If you are missing any documents, send an email to info@CredibleCoverage.com.*

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Please add any additional information you feel is important for us to know (e.g. explanation for any compliance history, if you are already contracted and need a release, if you would like to contract with any carrier/product not listed above).
I understand the information provided will be used on my behalf for onboarding with Credible Coverage LLC and contracting with insurance carriers.*

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Are you willing to step out of your comfort zone?*

YES!No...
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