HPUSA Contracting Request

Contracting Request Form
Contracting Request Type

New ContractTransfer ContractAdd State AppointmentOther
Release Letter from Current Upline and/or Transfer Forms*

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What type of products are you requesting?*

Medicare AdvantageMedicare SupplementACA / Under 65 Health (IU65)Life & AnnuitiesDental & VisionLong-Term CareHospital IndemnityCritical IllnessAccidentWorksite SolutionsInsurance AlternativesTravelPet
Medicare Advantage*

Aetna MA / SilverScript PDPAlignmentBannerBCBS of Arizona MAChristus MADevotedElevance/Anthem MAeternalHealthGold KidneyHealthSpring MAHealthSpring Med SuppHumanaImperialKaiserManhattan LifeMedica MAMolina MARegenceSCANUHC MAWellcare/CenteneVERDA Health Plan of ArizonaVERDA Health Plan of ArizonaOther
Medicare Supplement Carriers*

ACE Med SuppAetna Med SuppAflacBCBS of AZ Med SuppCigna Med SuppGTLHumanaINA Med SuppManhattan LifePhysicians MutualUHC Med SuppOther
ACA / Under 65 Health (IU65) Carriers*

AmbetterAntidoteBCBS of Arizona ACAElevance/Anthem ACACigna ACAMedica ACAMolina ACAOscarPremera ACASelect HealthUHC ACAOther
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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Life & Annuities Carriers*

BOSS (Life Quote & Apply)Axonic Insurance ServicesGTLManhattan LifeNational Life GroupOther
Dental and Vision Carriers*

NCD (MetLife and VSP)Manhattan LifeMetLife DentalOther
Travel Carriers*

IMG GlobalGeoBlueHTH TravelOther
Accident Carriers*

GTLLifeSecureNCD Accident PrimeZurich Accident DisabilityZurich Accident MedicalOther
Hospital Indemnity Carriers*

BOSS (Quote & Apply)GTLLifeSecureManhattan LifePrudentialOther
Critical Illness Carriers*

BOSS (Quote & Apply)GTLZurich Critical IllnessOther
Long Term Care Carriers*

BOSS (Quote & Apply)ChubbLifeSecure (Worksite Only)Other
Worksite Solutions*

Colonial LifeLifeSecure - LTC WorksiteManhattan LifeMetLifeOther
Pet Carriers*

My Primary Pet CareOther
Insurance Alternatives Carriers*

GO MD USAHooray Urgent CareMy Primary CareOther
States to be appointed in (Resident and/or Non-Resident)*

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
State Licenses (Resident and/or Non-Resident)*

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Agent Name*

First NameLast Name
Agent NPN*
Agent Email*
example@example.com
Are you appointing/contracting your Agency*

YesNo
Agency Name*
Agency NPN*
Agency Tax ID*
Comments
Additional Files

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Person completing this form:*

First NameLast Name
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Contracting Request Form