Enhanced Benefits - Enroller Information Form

1

Agent Name* This field is required.

First Name

Last Name

2

Cell Number* This field is required.

Area Code

Phone Number

3

Secondary Number

Area Code

Phone Number

4

Primary E-mail* This field is required.

please do not use a carrier email address as primary

5

Secondary E-mail

6

Fax Number

Area Code

Phone Number

7

Mailing Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

9

Are you interested in learning to work with new carriers and products?* This field is required.

Yes

No

10

Are you willing to travel out of state for enrollments?* This field is required.

Yes

No

11

Can you present and enroll insurance in Spanish?* This field is required.

Yes

No

12

Do you have current Errors & Omissions insurance?

Yes

No

13

Please list all carriers that you are currently licensed to represent. If you are licensed with Aflac or Colonial Life please include your agent number and carrier email address.* This field is required.

14

Comments

15

Which states do you have an active health and life license?* This field is required.list all states including Oklahoma