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 Name
Last Name
If You Don't Know Click "Not Sure"
Not Sure
Agent's Name
*
First Name
Last Name
Agent's Mobile
*
Format: (000) 000-0000.
Agent's Email
*
example@example.com
National Producer Number (NPN)
*
Date of Birth
-
Month
-
Day
Year
Date
Do you have an personal agency?
*
Please Select
Yes
No
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 MAPD
Anthem/Amerigroup
UHC
BCBS Michigan
Humana
Wellcare
HAP
Priority Health
Medical Mutual of Ohio
Cigna MAPD
Molina
Zing
IU Health
Blue Cross Blue Shield New Mexico
Devoted
McLaren / MDwise
Alignment Health
Physicians Mutual
If you marked contracted with any of the above carriers, please see options below:
Please Select
I can get a release letter
I cannot get a release letter
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
City
State / Province
Postal / Zip Code
Local Contract Type Requesting (Please click 'Other' if only specific carriers are wanted)
*
Medicare Advantage Carriers
Medicare Supplement Carriers
Final Expense Carriers
Life Carriers
Annuity Carriers
Other
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
SUBMIT TO ADVOCATE
Should be Empty: