NBG Contracting Request Form

Contracting Request Form

Please complete this form to submit new contracting requests or changes to an existing agent's contracting, hierarchy, compensation, or advance structure. For custom or bulk carrier compensation requests, please email Support@NationalBrokersGroup.com with the carrier name(s) and the compensation level you would like to obtain and details regarding how you would like the compensation split. Please ensure you are also including the Upline Agent's writing number for all new contracting or contract changes.
- ADMIN PASSWORD
- Submission Details
- Describe This Submission
- AGENT NOTES: Please inform us of anything relevant to this submission, input N/A if not needed.
- Will this person be contracting as a business?
- For BUSINESS contracts, include below EIN number
- For BUSINESS contracts, include below BUSINESS NPN NUMBER (This is NOT the same NPN number as the Principal Agent)
- Agent Information
- What is the Agent's Full Legal Name (As seen on SureLC/NIPR)
- What is the Agent's NPN Number
- What is the Agent's Email Address
  example@example.com
- What is the Agent's Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Please list the full name of the carriers the agent would like to appoint with
- Compensation and Upline Information
- Please Select Comp Level
- Override Percentage: Select in the override percentage the UPLINE wants to earn off this agent. (In 5% increments when applicable by carrier)
- List the UPLINE'S Full Legal Name
- List the UPLINE's NPN Number
- List the UPLINE's Email
  example@example.com
- List the UPLINE's Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Please list UPLINE's Carrier Name & Writing Numbers for ALL carriers downline is appointing with:
- Please list the NAME and WRITING NUMBER for the carriers the agent has active that you would like to terminate:
- Please list UPLINE's Carrier Name & Writing Numbers for ALL carriers downline is appointing with
- SUBMIT RELEASE DOCUMENTS BELOW
  
  Cancelof
- Thank you for completing this form. For any questions, please reach out to Support@NationalBrokersGroup.com
- Please list the name of ADMIN/TEAM MEMBER submitting this form
- Please list AGENCY/TEAM associated with this contracting request
Should be Empty:

Contracting Request Form

Submission Details

Agent Information

Compensation and Upline Information