Initial Call Request Form

Initial Request Form

Once completed, this form goes directly to the sales team for an interview/screening call. If special instructions or circumstances are needed please give details in the note section found at the bottom of this form. Please give us a call with any questions -> (800) 943-2386
Your Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Birthday

MonthDayYear
Date
National Producer Number (NPN)*
Do you have a personal agency?*
If yes, what is your Personal Agency Name?
If you have an personal agency, what is your agency NPN?
Personal Agency TIN/EIN#
Are you already contracted with any carriers? (Select ALL that Apply)

Aetna MAPDAnthem/AmerigroupUHCBCBS MichiganHumanaWellcareHAPPriority HealthMedical Mutual of OhioCigna MAPDMolinaZingIU HealthBlue Cross Blue Shield New MexicoDevotedMcLaren / MDwiseAlignment HealthPhysicians Mutual
If you marked contracted with any of the above carriers, please see options below:
Note*If your prior contract paid commissions to an upline other than yourself, then you likely do not own your book of business.
Company
Lead Source
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Local Contract Type Requesting (Please click 'Other' if only specific carriers are wanted)*

Medicare Advantage CarriersMedicare Supplement CarriersFinal Expense CarriersLife CarriersAnnuity CarriersOther
Notes (Please give special instructions on carriers wanted or not wanted, if applicable)
User ID for integration (Not Visible to Agents)
New Case for new contact in Salesforce
New Contact Case Info
Contracting ID
Should be Empty:

Initial Request Form