Connecture Agent Access Request Form

Connecture Agent Access Request Form
Who is filling out this form? (email address)*
This form should be completed by an SMA Sales Representative.
What type of request is this?*

New AccessAdditional Carrier Selling Permissions
Agent Name*
Please include first and last name.
Email*
example@example.com
Agent Phone*
NPN*
Is Agent Direct to SMA?*

YesNo
Agency Name
Agency ID
Permission Level*

Enrollment BrokerQuoter Broker
Licensed Carriers*

AetnaAnthemAllwell/CenteneCareMoreCignaHumanaUHCMolinaWellCareBrightHealth
Aetna Licensed States*

ALAZAKARCACOCTDEFLGAHIIDILINIAKSKYLAMAMDMEMIMNMOMSMTNCNDNENMNVNYOHOKORPARISCTNTXUTVAVTWAWIWVWY
Aetna Agent Producer ID*
Allwell/Centene Licensed States*

ALAZAKARCACOCTDEFLGAHIIDILINIAKSKYLAMAMDMEMIMNMOMSMTNCNDNENMNVNYOHOKORPARISCTNTXUTVAVTWAWIWVWY
Allwell/Centene Agent Producer ID*
Anthem Licensed States*

ALAZAKARCACOCTDEFLGAHIIDILINIAKSKYLAMAMDMEMIMNMOMSMTNCNDNENMNVNYOHOKORPARISCTNTXUTVAVTWAWIWVWY
Anthem Agent Producer ID*
CareMore Licensed States*

ALAZAKARCACOCTDEFLGAHIIDILINIAKSKYLAMAMDMEMIMNMOMSMTNCNDNENMNVNYOHOKORPARISCTNTXUTVAVTWAWIWVWY
CareMore Agent Producer ID*
Cigna Licensed States*

ALAZAKARCACOCTDEFLGAHIIDILINIAKSKYLAMAMDMEMIMNMOMSMTNCNDNENMNVNYOHOKORPARISCTNTXUTVAVTWAWIWVWY
Cigna Agent Producer ID*
HealthNet Licensed States*

ALAZAKARCACOCTDEFLGAHIIDILINIAKSKYLAMAMDMEMIMNMOMSMTNCNDNENMNVNYOHOKORPARISCTNTXUTVAVTWAWIWVWY
HealthNet Agent Producer ID*
Humana Licensed States*

ALAZAKARCACOCTDEFLGAHIIDILINIAKSKYLAMAMDMEMIMNMOMSMTNCNDNENMNVNYOHOKORPARISCTNTXUTVAVTWAWIWVWY
Humana Agent Producer ID*
UHC Licensed States*

ALAZAKARCACOCTDEFLGAHIIDILINIAKSKYLAMAMDMEMIMNMOMSMTNCNDNENMNVNYOHOKORPARISCTNTXUTVAVTWAWIWVWY
UHC Agent Producer ID*
Plan Type

MAMAPDPDPALL_MEDICARE_PLUS_GAP
Assign Task
example@example.com
Follwer
example@example.com
Should be Empty: