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*

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
Medicare Supplement Carriers*

ACEAetnaAflacBanker FidelityBCBS of ArizonaHealthSpringGTLHumanaInsurance Company of North AmericaMutual of OmahaPhysician MutualPremera Blue CrossUnited HealthcareWellabeOther
ACA / Under 65 Health (IU65) Carriers*

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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Life & Annuities Carriers*

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

AFE (MetLife & VSP)AmertitasCignaHumanaManhattanLifeMetLife (Worksite)NCD (MetLife & VSP)Other
Travel Carriers*

BCBS Global SolutionsIMG GlobalHTH TravelOther
Accident Carriers*

GTLLifeSecureManhattan LifeNCD Accident PrimeZurich (AFE)Other
Hospital Indemnity Carriers*

BOSS (Quote & Apply)GTLLifeSecureManhattan LifePrudential (AFE)Other
Critical Illness Carriers*

BOSS (Quote & Apply)GTLLifeSecureZurich (AFE)Other
Long Term Care Carriers*

BOSS (Quote & Apply)Chubb (AFE)LifeSecure (Worksite Only)Other
Worksite Solutions*

Colonial LifeGO MD USALifeSecure (LTC Only)Manhattan LifeMetLifeOther
Pet Carriers*

My Primary Pet CareOther
Insurance Alternatives Carriers*

GO MD USAHooray Urgent Care (AFE)My Primary Care (AFE)Other
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