UIG New Producer Info Form

New Producer Information Form

for agents of Universal Indemnity Group and Financial Services(UIG)
In order to provide the best possible service to our agents and their downlines, please complete this simple information form so that you are properly set up in our system prior to submitting contracting.
Request Type

NEW Change to Previous Submission
APPOINTMENT TYPE *

Individual Corporation (Principal Only)
Agent Name *

First Name Last Name
SSN *
Date of Birth *

Month Day Year
Agent NPN *
Agency Name *
Tax ID Number for Agency *
Agency NPN *

Business Address *

Home Address

E-mail *
Do you have a website? *

Yes No
Website *
Preferred Phone Number *

Area Code Phone Number
Additional Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
Contract Request

Aetna Anthem (GA, TN, and VA only) Humana WellCare
Are you currently contracted with Aetna?

Yes No I don't know
In which state(s) do you want to get contracted for Anthem? *

Georgia Virginia Tennessee
NOTE: Anthem requires your Social Security Number to initiate the contract. A Broker Liaison from GarityAdvantage will call you to obtain in order to send the contract invitation. You may also call us directly at 800-234-9488.
Are you currently contracted with Anthem?

Yes No I don't know
Are you currently contracted with Humana?

Yes No I don't know
Are you currently contracted with WellCare?

Yes No I don't know
Comments/Questions:
Contact us with any questions: 877.679.9939
For UIG Use Only
Contract Level
General Agent/Upline
Comments/Questions:
Approved by
Approval Date

Month Day Year
Date
Should be Empty:

New Producer Information Form