Contract Submission Page

Use this online form submission to send producer profile, contracting, hierarchy & commission requests directly to the contracting team!

NEW COMBINED APPOINTMENT FORM

Agent Name *

First

Last

National Producer Number (NPN) *

Appoint As *

• Agent
• Agency

Agency Name *

Agency National Producer Number (NPN) *

Direct Upline Hierarchy *

Appointment State(s) *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Carrier 1 *--- Select Choice ---Aetna (MA)AflacAlignment HealthAllstate/National GeneralAmbetterAmerican Benefit LifeAmerican NationalAmericoAmeritasAssurityBlue Cross & Blue Shield (MA)Blue Cross & Blue Shield (ACA)Devoted HealthForestersGerberGTLHealthSpring (Cigna MA)HealthSpring (Cigna Supplemental)HealthTeam AdvantageHeartland NationalHumanaIllinois MutualINALumosManhattanLifeMutual of OmahaOccidental LifeOscar HealthPhysicians MutualProtective LifeTransamerica PremierUnitedHealthcare (ACA)UnitedHealthcare (MA)UnitedHealthOne (Golden Rule)Wellabe (Medico)WellcareWoodmenLifeOther (Detail in Notes)

Carrier 1 Product Line(s) *

Carrier 1 Commission Level *

• Street Level for All
• LOA for All
• Other (Detail in Notes)

Carrier 1 Advances Requested *

• Yes
• No

Carrier 1 # Months Advance Requested *

Carrier #1 Notes

Add A Second Carrier? *--- Select Choice ---YesNo

Carrier 2Aetna (MA)AflacAlignment HealthAllstate/National GeneralAmbetterAmerican Benefit LifeAmerican NationalAmericoAmeritasAssurityBlue Cross & Blue Shield (MA)Blue Cross & Blue Shield (ACA)Devoted HealthForestersGerberGTLHealthSpring (Cigna MA)HealthSpring (Cigna Supplemental)HealthTeam AdvantageHeartland NationalHumanaIllinois MutualINALumosManhattanLifeMutual of OmahaOccidental LifeOscar HealthPhysicians MutualProtective LifeTransamerica PremierUnitedHealthcare (ACA)UnitedHealthcare (MA)UnitedHealthOne (Golden Rule)Wellabe (Medico)WellcareWoodmenLifeOther (Detail in Notes)

Carrier 2 Product Line(s)

Carrier 2 Commission Level *

• Street Level for All
• LOA for All
• Other (Detail in Notes)

Carrier 2 Advances Requested *

• Yes
• No

Carrier 2 # Months Advance Requested

Carrier #2 Notes

Add A Third Carrier? *--- Select Choice ---YesNo

Carrier 3Aetna (MA)AflacAlignment HealthAllstate/National GeneralAmbetterAmerican Benefit LifeAmerican NationalAmericoAmeritasAssurityBlue Cross & Blue Shield (MA)Blue Cross & Blue Shield (ACA)Devoted HealthForestersGerberGTLHealthSpring (Cigna MA)HealthSpring (Cigna Supplemental)HealthTeam AdvantageHeartland NationalHumanaIllinois MutualINALumosManhattanLifeMutual of OmahaOccidental LifeOscar HealthPhysicians MutualProtective LifeTransamerica PremierUnitedHealthcare (ACA)UnitedHealthcare (MA)UnitedHealthOne (Golden Rule)Wellabe (Medico)WellcareWoodmenLifeOther (Detail in Notes)

Carrier 3 Product Line(s)

Carrier 3 Commission Level *

• Street Level for All
• LOA for All
• Other (Detail in Notes)

Carrier 3 Advances Requested *

• Yes
• No

Carrier 3 # Months Advance Requested

Carrier #3 Notes

Add A Fourth Carrier? *--- Select Choice ---YesNo

Carrier 4Aetna (MA)AflacAlignment HealthAllstate/National GeneralAmbetterAmerican Benefit LifeAmerican NationalAmericoAmeritasAssurityBlue Cross & Blue Shield (MA)Blue Cross & Blue Shield (ACA)Devoted HealthForestersGerberGTLHealthSpring (Cigna MA)HealthSpring (Cigna Supplemental)HealthTeam AdvantageHeartland NationalHumanaIllinois MutualINALumosManhattanLifeMutual of OmahaOccidental LifeOscar HealthPhysicians MutualProtective LifeTransamerica PremierUnitedHealthcare (ACA)UnitedHealthcare (MA)UnitedHealthOne (Golden Rule)Wellabe (Medico)WellcareWoodmenLifeOther (Detail in Notes)

Carrier 4 Product Line(s)

Carrier 4 Commission Level *

• Street Level for All
• LOA for All
• Other (Detail in Notes)

Carrier 4 Advances Requested *

• Yes
• No

Carrier 4 # Months Advance Requested

Carrier #4 Notes

Add A Fifth Carrier? *--- Select Choice ---YesNo

Carrier 5Aetna (MA)AflacAlignment HealthAllstate/National GeneralAmbetterAmerican Benefit LifeAmerican NationalAmericoAmeritasAssurityBlue Cross & Blue Shield (MA)Blue Cross & Blue Shield (ACA)Devoted HealthForestersGerberGTLHealthSpring (Cigna MA)HealthSpring (Cigna Supplemental)HealthTeam AdvantageHeartland NationalHumanaIllinois MutualINALumosManhattanLifeMutual of OmahaOccidental LifeOscar HealthPhysicians MutualProtective LifeTransamerica PremierUnitedHealthcare (ACA)UnitedHealthcare (MA)UnitedHealthOne (Golden Rule)Wellabe (Medico)WellcareWoodmenLifeOther (Detail in Notes)

Carrier 5 Product Line(s)

Carrier 5 Commission Level *

• Street Level for All
• LOA for All
• Other (Detail in Notes)

Carrier 5 Advances Requested *

• Yes
• No

Carrier 5 # Months Advance Requested

Carrier #5 Notes

Agent Advisor *

Advisor Email *

Advisor Notes

Attach Any Supporting Forms

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Contracting Contact *

• Kristen Hailey (Agent Last Name A - F, R - Z)
• Nancy Benton (Agent Last Name G - Q)

Submit Form

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