Health Plans USA Agent Intake/Contracting Form

Agent Intake Form

Please fill out the information below.
Agent Name*

First NameLast Name
Agent NPN *
(Principal of Agency)
YesNo
Agency Name*
Agency NPN*
Agency EIN*
Resident State*
Resident State
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
State Licenses (Resident and/or Non-Resident)*

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States (multiple selections using the "Ctrl" key and clicking)
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Mailing Address (Business and Residential)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB*

MonthDayYear
Date
SSN*
YesNo I am not contracted with any carriers.
Current Contracted Carriers

Please select the carriers you are currently contracted with.
Please list any Agencies, Uplines, or FMOs you are currently contracted with.
AetnaAlignmentBannerBCBS of ArizonaBCBS of KansasBCBS of IL (HCSC)BCBS of MT (HCSC)BCBS of NM (HCSC)BCBS of OK (HCSC)BCBS of TX (HCSC)ChristusDevotedElevance / AnthemEssenceeternalHealthGold KidneyHealth First Health PlansHealthSpringHumanaImperialKaiserMedicaMolinaPacific SourceRegenceSCANSelect HealthUCLA HealthUnited HealthcareVERDA Health Plan of ArizonaVERDA Health Plan of TexasWellcareOther
ACEAetnaAflacBanker FidelityBCBS of ArizonaHealthSpringGTLHumanaInsurance Company of North AmericaMutual of OmahaPhysician MutualPremera Blue CrossUnited HealthcareWellabeOther
Antidote HealthAmbetterBCBS of ArizonaCignaCareSourceElevance/AnthemMedicaMolinaOscarPremera Blue CrossSelect HealthUnited HealthcareWellpointOther
Please provide FFM and/or State Based Certificate for ACA carrier.*

State Based Certificate states - AR, CA, CO, CT, DC, GA, ID, KY, ME, MD, MA, MN, NV, NJ, NM, NY, OR, PA, RI, VT, VA, WA **Failure to provide necessary certificate will cause link to not be requested**
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BOSS (Quote & Apply)Axonic Insurance ServicesGTLManhattan LifeNational Life GroupOther
AFE (MetLife & VSP)AmertitasCignaHumanaManhattanLifeMetLife (Worksite)NCD (MetLife & VSP)Other
BCBS Global SolutionsHTH TravelIMG GlobalOther
My Primary Pet CareOther
Chubb (AFE)GTLLifeSecureManhattanLifeNCDPrudential (AFE)Zurich (AFE)Other
GO MD USAHooray Urgent Care (AFE)My Primary Care (AFE)Other
Carriers Not Listed
YesNo
New Carrier Request

Please select the carriers that you would like to get contracted with. If none, skip this section.
AetnaAlignmentBannerBCBS of ArizonaBCBS of KansasBCBS of IL (HCSC)BCBS of MT (HCSC)BCBS of NM (HCSC)BCBS of OK (HCSC)BCBS of TX (HCSC)ChristusDevotedElevance / AnthemEssenceeternalHealthGold KidneyHealth First Health PlansHealthSpringHumanaImperialKaiserMedicaMolinaPacific SourceRegenceSCANSelect HealthUCLA HealthUnited HealthcareVERDA Health Plan of ArizonaVERDA Health Plan of TexasWellcareOther
ACEAetnaAflacBanker FidelityBCBS of ArizonaHealthSpringGTLHumanaInsurance Company of North AmericaMutual of OmahaPhysician MutualPremera Blue CrossUnited HealthcareWellabeOther
Antidote HealthAmbetterBCBS of ArizonaCignaCareSourceElevance/AnthemMedicaMolinaOscarPremera Blue CrossSelect HealthUnited HealthcareWellpointOther
Please provide FFM and/or State Based Certificate for ACA carrier.*

State Based Certificate states - AR, CA, CO, CT, DC, GA, ID, KY, ME, MD, MA, MN, NV, NJ, NM, NY, OR, PA, RI, VT, VA, WA **Failure to provide necessary certificate will cause link to not be requested**
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BOSS (Quote & Apply)Axonic Insurance ServicesColonial LifeGTLManhattan LifeNational Life GroupOther
AmertitasCignaHumanaManhattanLifeMetLifeNCD (MetLife & VSP)Other
BCBS Global SolutionsHTH TravelIMG GlobalOther
My Primary Pet CareOther
Chubb (AFE)GTLLifeSecureManhattanLifeNCDPrudential (AFE)Zurich (AFE)Other
GO MD USAHooray Urgent Care (AFE)My Primary Care (AFE)Other
Carriers Not Listed
Click the links below to complete and sign required forms
Health Plans USA W9 and EFT Form
Yes
Health Plans USA Agent Agreement
Yes
Health Plans USA Agency Agreement
Yes
Notes
Files (E&O, AHIP, etc.)*

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SMS Consent
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Agent Intake Form

Current Contracted Carriers

New Carrier Request

Click the links below to complete and sign required forms