Health Carrier Contract Request Form

  • Health Carrier Contract Request Form

    Please complete all required fields. Please note that this is a request for a carrier contract to be emailed to you from the carrier portal.
  • Please select the carrier(s) you want to get contracted with?*

  • Atrio is only available in the state of Oregon.  Please be sure you are licensed in that state before requesting the carrier.

  • Baylor Scott and White Health Plans will only appoint you if you are a resident of Texas.  Please only request if you reside in TX.

  • HealthSpring requires you to have a separate email address for your agency.  Please be sure to use a different one for yourself and your agency on their portal when completing contracting.

  • Cigna Health & Life Ins Co (Cigna Med Supp) requires you to have a separate email address for your agency.  Please be sure to use a different one for yourself and your agency on their portal when completing contracting.

  • Contract Set up*
  • Blue KC Products Requested*
  • BCBS of SC - Do you have a RESIDENT license in SC, NC or GA?*
  • BCBS of SC - Please select any additional products you would like to sell other than MA*

  • Agent Information

  • Agency Information

    Only complete if you are contracting as an entity
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Contract Information

  • American Benefit Life Commission Advance Options*
  • American Home Life Commission Options (9 month Advance is the only option)*
  • With Heartland, what products do you want to be contracted with?*
  • Heartland Advance Options
  • With BCBS of NC, which products would you like to get contracted with?*
  • Cigna Med Supp Advance Mode*
  • With Highmark BCBS, what products do you want to be contracted with?*
  • Commission Advance Mode:
  • Physicians Mutual Advance Mode*
  • With Select Health, which products would you like to get contracted with?*
  • Commission Advancing*
  • Washington National Advance Mode*
  • Atrio - Have you previously contracted with Atrio?*
  • Elevance (Anthem) States Available*
  • Banker's Fidelity States Available*
  • BCBS (IL, TX, NM, OK ,MT) States Available*
  • With BCBS (IL, TX, NM, OK, MT) LOA agents, are you covered under your payee agency's E&O?*
  • Globe Life & Accident States Available*
  • Highmark BCBS States Available*
  • Highmark Wholecare states available *DSNP ONLY**
  • Kaiser States Available*
  • Select Health States Available*
  • United American States Available*
  • Washington National - Please mark the Products you would like to offer to your clients*

  • Banner University requires a copy of your Arizona state license, an Individual E&O certificate, and below AOC form.  Please upload both documents below

  • BCBS of NC requires you to upload your AHIP in order to receive a contracting request. Please upload it below.

  • **Highmark BCBS and Highmark Wholecare require a copy of your E&O coverage as well as an up to date license for any state you would like to be appointed in.  Please be sure to upload these required documents, along with the below AOC form

  • **People's Health requires a copy of your E&O coverage as well as a copy of your Louisiana insurance license in addition to the documents mentioned above.  Please be sure to upload these required documents.

  • Physicians Mutual does not charge resident state appointment fees. Please reference the below fee chart for non-resident appointment fees what will be applied at the time business is written (with the exception of MT and PA. Please contact Premier to be appointed in MT or PA prior to the submission of business).

  • By selecting the states above, I agree to pay all appointment fees that will incur due to my selections.  I understand that each state has their own set fees for resident, non-resident, individual, and agency appointments. It is my responsibility to pay these fees.

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