New Agent Contracting
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
NPN Number
*
E&O
*
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List the state and License number that corresponds to your contracting request.
*
EX: Maryland 3245671
Terms and Conditions
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I agree that submitting this information is true to the best of my knowledge and any misinformation submitted or omitted is the responsibility and liability of (myself) the agent requesting contracting listed on this form.
I agree that information will be kept up to date and is my responsibility to notify the agency of any changes included but not limited to any license expiration, or revoked status, address, phone number, email on file, and any E&O changes.
I agree that even though I am represented by the Beat My Rates Agency, I am contracted as an independent contractor and will be paid based on the carriers payment schedule.
I agree that contracting could be terminated at any time with written notice due to misconduct, licensing violations etc. based on the carriers requirements.
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We NEVER share your information with anyone.
Should be Empty:
We NEVER share your information with anyone.