Contracting Paperwork Submission Form
Use this form to submit paper contracts only.
I am submitting a contract for:
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Myself
My Downline Agent
Name of Person Submitting this Form (if different from the Agent Name
First Name
Last Name
Agent Name on Contract
*
First Name
Last Name
Contract Submission Date
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-
Month
-
Day
Year
Date
Carrier Name (what contract are you submitting)?
*
Please Select
American Amicable
American Continental (Aetna Med Supp)
Cigna Supplemental Benefits
Columbian Financial Group
Foresters
Guarantee Trust Life (GTL)
Humana
Mutual of Omaha
Royal Neighbors
Other
If you selected "Other" on the question above, please enter the carrier name.
Who is the immediate upline on this contract?
*
File Upload
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I completed the attached contract submission, truthfully, and accurately.
*
Yes
No
N/A (I am submitting the contract on behalf of a downline agent)
I agree to follow all CMS, Carrier, TSS, and other Marketing rules. I understand the importance of Compliance and will adhere to all established guidelines while representing this carrier.
*
Yes
No
N/A (I am submitting the contract on behalf of a downline agent)
Signature of Submitter
*
Submit
Should be Empty: