Tyler (DOS) - Initial Contracting Request Form

Initial Contracting Request Form

Once completed this form goes directly to the contracting team to send out contracts for the specified agent. If special instructions or circumstances are needed please give details in note section. Please give us a call with any questions (800) 943-2386
(Agency Builder/Recruiter)

First NameLast Name
If You Don't Know Click "Not Sure"

Not Sure
Agent's Name*

First NameLast Name
Agent's Mobile*
Agent's Email*
example@example.com
National Producer Number (NPN)*
Date of Birth

MonthDayYear
Date
Do you have an personal agency?*
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.
Agent's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / 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)
Owner ID for integration (Not Visible to Agents)
New Case for new contact in Salesforce
New Contact Case Info
Contracting ID
Should be Empty: