Humana MGA Form

Humana

Agent To General Agency Assignment Form
Agent or Agency Name*
Humana SAN*
Address*
Phone*

Area CodePhone Number
(Email Address)*
example@example.com
Indicate below which segment(s) of business this affiliation applies to:
Dental & Vision (Place Your Initials Below)

Clear
Medicare (Place Your Initials Below)

Clear
Achieve - Med Supp (Place Your Initials Below)

Clear
Are you the Principal Officer of an agency currently contracted with Humana?*

YesNo
If yes, please provide the name and SAN/TIN to re-align the agency:
Agency Name
Agency SAN/TIN
If an agency is being released and receives commission on behalf of any agents, each agent must submit an MGA assignment form in addition to the agency. If there are agents who are not realigning with the agency, a Delegated Commission Assignment Form must be submitted to update their payee. Failure to do so could prevent or delay the processing of this request.

I understand that if I would like to discontinue my relationship with the above GA at any time, I will need to follow the Agent Release Policy as outlined in the Producer Partnership Plan.
Agent/Agency Name (Print)*
Agent/Agency SAN (Print)*
Agent/Agency Signature*

Clear
Date*

MonthDayYear
Date
Select the "Preview PDF" button below to view and download a copy of your completed form.
Note: If you do not wish to digitally complete the form, you may download a copy of the form here: https://workdrive.zohoexternal.com/external/830119208a691b7c8379404429f0dea87dfc6a0b4b8747cb0f6648070ef7be68
Should be Empty: