ACA Contracting

- ACA CONTRACTING REQUEST -

Create Your Agent File By Completing The Following Information:

NOTE BEFORE PROCEEDING:

Surancebay is a flash based platform. For the best user experience, please use the Google Chrome Browser. Click here for assistance with flash enabling.

You will need to attach a copy of the following information before being able to submit this contracting request: E&O Insurance Certificate & State Insurance License(s)

Please complete ALL fields with a red *. If all items are not completed the contracting will not be processed.

Name of your Immediate Upline *

Do Not Change This Field If Already Populated With Upline Name

Commission Level

Agent Name (exactly as it reads on your insurance license):

First Name *

Include Middle Name If Listed On License

Last Name *

SS# *

Date of Birth *

Date

Gender *

Male Female Other

Phone Number *

Area Code Phone Number

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

County *

Agent National Producer Number (NPN) *

NPN Lookup: https://nipr.com/help/look-up-your-npn

Resident License # *

Please attach a copy of your Insurance License(s)

Browse Files

Please attach a copy of your E&O Insurance Certificate

Browse Files

Please attach a copy of any Release Letters from Previous Uplines (if applicable)

Browse Files

Are you contracting as a business entity? *

Yes No

Agency Name (if contracting as a business entity) *

Agency Address (if contracting as a business entity) *

Agency Street Address

Agency Street Address Line 2

Agency City Agency State / Province

Agency Postal / Zip Code

Tax ID # (if contracting as a business entity) *

Agency NPN # (if contracting as a business entity) *

Signature *

Clear

When proceeding to contracting via the link below, you MUST register on Surancebay as a "NEW USER" even if you have a current Surancebay account.

Click "SUBIT & CONTINUE TO CONTRACTING" below to begin your ACA contacting through Surancebay via our contracting partner.

Appointment requests will be delayed if all of the above information is NOT completed and you do not submit your requests via the contracting link below.

The contracting process for Medicare Advantage Carriers can take up to 3 weeks from the date the contract is *submitted. *Certifications are required BEFORE contracts will be processed and you are issued a writing number.

Appointment requests will be delayed if all of the above information is NOT completed.

Contracting