HPUSA Contracting Request

Contracting Request Form
Contracting Request Type

Other
Release Letter from Current Upline and/or Transfer Forms

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What type of products are you requesting?
Medicare Advantage

Other
Medicare Supplement Carriers

Other
ACA / Under 65 Health (IU65) Carriers

Other
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

Other
Dental and Vision Carriers

Other
Travel Carriers

Other
Accident Carriers

Other
Hospital Indemnity Carriers

Other
Critical Illness Carriers

Other
Long Term Care Carriers

Other
Worksite Solutions

Other
Pet Carriers

Other
Insurance Alternatives Carriers

Other
States to be appointed in (Resident and/or Non-Resident)
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
Agency Name
Agency NPN
Agency Tax ID
Comments
Additional Files

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Person completing this form:

First NameLast Name
We will email you contracting instructions after you complete this form.
Should be Empty:

Contracting Request Form