New Agent Contracting Form

New Agent Contracting Form

Fill this form out with your information to start the onboarding and contracting process. Once this form is submitted a Welcome email with carrier contracting instructions will immediately go out to the email you provided. GAMEPLAN BENEFITS INTERNAL USE ONLY.
Name*

First NameLast Name
Email*
example@example.com
Date of Birth*
MM/DD/YYYY
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
We will need your Social Security Number. (please provide below the best way to receive this information.)*
Best way for GamePlan Benefits to collect your SSN
NPN# (national producer number)*
Your Answer
CARRIER ANNUITY CONTRACTS AVAILABLE (after first sale more carriers available). SELECT CARRIERS YOU WANT TO CONTRACT WITH*

American LifeAtheneBaltimore Life(LOA)Delaware Life (LOA)EquitrustF&GNorth AmericanRevol OneOther/None
CARRIER LIFE CONTRACTS AVAILABLE: (after first sale more carriers available) SELECT CARRIERS YOU WANT TO CONTRACT WITH*

AETNAAMERICAN AMICABLEAIGBANNER LIFEKANSAS CITY LIFELGAMUTUAL OF OMAHANATIONAL LIFE GROUPNORTH AMERICANSBLITRANSAMERICAUHLFORESTERS FINANCIALOther/None
CARRIER IUL/IBC CONTRACTS AVAIABLE: SELECT CARRIERS YOU WANT TO CONTRACT WITH*

ALLIANZ LIFENATIONAL LIFE GROUPNORTH AMERICANMUTUAL TRUST LIFELAFAYETTE LIFEOther/None
CARRIER HEALTH CONTRACTS AVAILABLE: SELECT ONES YOU ARE INTERESTED IN.

ACA/MEDICAREGROUP HEALTHREFERRAL OPTIONS (ask manager about opportunity)None
Which do you hold an active License? Select all that apply*

LifeHealthAnnuitySeries 6,63
Which states do you hold an active license for the above? (list all writing business in)*
List ALL: States actively writing business
What lead sources do you currently work? Select all that apply*

Annuity LeadsLife InsuranceHealth (ACA/Medicare/Turning 65)Indexed Universal LifePremium FinancingInfinite Banking LeadsWills & TrustLife SettlementI would like to speak to someone who can help me with Leads
Name of your GamePlan Benefits manager? (offering you the contracts)*
Manager First and Last Name
NOTES: Anything that would help our Hiring/Contracting team. If you have written any business in the last 6 months with any of the carrier's you would like to contract with please list here as well. (you may need a release)
Notes that may help our team
Should be Empty: