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?*

AetnaAlignmentAmerican Benefit LifeAmerican Home LifeArkansas Blue Cross Blue ShieldAtrioBanker's FidelityBanner UniversityBaylor Scott and White Health PlansBCBS (IL, TX, NM, OK, MT)BCBS of AZBCBS of MIBCBS of NCBCBS of NEBCBS of SCBlue Shield of CACigna Health & Life Ins CoClear Spring/CCAIClover HealthDevotedElevance (Anthem)EmblemEssence HealthcareFlorida BlueFreedom & OptimumGlobe Life & AccidentGlobe Life Insurance Company of NYGolden RuleHeartlandHealthSpringHighmarkHumanaKaiserManhattanLife Insurance & Annuity Company (DVH, STC, CHS, HI)MediGoldMolinaNational Health Ins CoPhysicians MutualPivot HealthRegenceSCAN Health PlanSelect HealthUnited AmericanUnitedHealthcareWashington NationalWellCareZing
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.
Contract Set up*

Individual AgentLicensed Only AgentAgency
United American / Globe Life & Accident / Globe Life Insurance Co of NY
A paper contract is required when contracting as an agency. Please reach out to your marketer to obtain a copy of the correct contract
Blue KC Products Requested*

Medicare AdvantageACA
BCBS of SC - Do you have a RESIDENT license in SC, NC or GA?*

YesNo
BCBS of SC - Please select any additional products you would like to sell other than MA*

Med SuppIndivudual
Agent Information
Agent Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender
Agent NPN*
Agent SSN (Numeric only)*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agency Information

Only complete if you are contracting as an entity
Agency Name*
AgencyTax ID*
Agency NPN*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agency County
E-mail Address*
example@example.com
Business Phone Number*
Fax Number
Please enter a valid phone number.
Home Phone Number*
Please enter a valid phone number.
Contract Information
Commission Level*
Upline approved level*
Immediate Upline Agent/Agency*
Please no abbreviations or nicknames
UHC Upline Writing Number
American Benefit Life Commission Advance Options*

As Earned6 months9 months12 months (not available for all product lines)
American Home Life Commission Options (9 month Advance is the only option)*

Pay on ApprovalPay on DraftNo Advance
Agent Resident License Number*
With Heartland, what products do you want to be contracted with?*

HealthAnnuitiesBoth Health and Annuities
Heartland Advance Options

As Earned3 months6 months9 months
With BCBS of NC, which products would you like to get contracted with?*

DentalMedicare AdvantageMedicare SupplementACA
With BCBS of NC, What COUNTY do you live in?*
BCBS of NC requires your NC state license number. Please provide it below*
Cigna Med Supp Advance Mode*

As Earned6 months9 months12 months15 months
With Highmark, what products do you want to be contracted with?*

Med SuppMAPDDSNP (Highmark Wholecare -DE & PA only)
With HealthSpring, what products would you like to be contracted with?*

MAPDPDPBoth MAPD and PDP
Commission Advance Mode:

As Earned3 Months4 Months6 Months9 Months (if available, if not default to highest mode)12 Months (if available, if not default to highest mode)
Physicians Mutual Advance Mode*

As Earned11 months
Commission Advancing*

YesNo
Washington National Advance Mode*

As Earned9 Months
Atrio - Have you previously contracted with Atrio?*

YesNo
Are you currently appointed to sell AR BCBS?*
Is your agency located in a bordering county to AR?
Do you have agents that reside in AR?*
How many health policies in AR do you currently sell in a year?*
Have you completed your AHIP?*
Why do you want an appointment with AR BCBS?*
Elevance (Anthem) States Available*

AZ - WellpointCA - Blue CrossCO - BCBSCT - BCBSFL - Simply HealthGA - BCBSIA - WellpointIN - BCBSKS - Healthy BlueKY - BCBSLA - HealthyME - BCBSME - Joint VenturesMO - BCBSMO - Healthy BlueNH - BCBSNJ - WellpointNV - BCBSNY - BCBSOH - BCBSSC - WellpointTN - WellpointTX - WellpointVA - BCBSWA - WellpointWI - BCBSWV - Wellpoint
Banker's Fidelity States Available*

AL (ACLAC)AR (ACLAC)AZ (ACLAC)CO (ACLAC)GA (ACLAC)IA (BFAC)IL (BFAC/ACLAC)IN (ACLAC)KS (ACLAC)KY (BFAC)NE (BFAC)LA (BFAC)MD (BFAC)MO (BFLIC)MS (ACLAC)MT (ACLAC)NJ (BFAC)NC (ACLAC)ND (ACLAC)NM (ACLAC)OH (BFAC/ACLAC)OK (BFAC)PA (BFAC)SC (BFAC)TN (BFAC)TX (ACLAC)UT (BFAC)VA (BFAC)WV (BFAC)
Banner University- Which state do you hold a resident license in?*
BCBS (IL, TX, NM, OK ,MT) States Available*

ILNMOKTXMT
With BCBS (IL, TX, NM, OK, MT) LOA agents, are you covered under your payee agency's E&O?*

YesNo
HealthSpring States Available both MAPD and PDP Products*

ALARAZCOCTDCDEFLGAILKSKYMDMOMSNJNMNCNVNYOHOKORPASCTNTXUTVAWA
HealthSpring States Available For PDP Products Only*

AKCAHIIAID*INLAMAMEMIMNMTNDNENHNVPRRISDVTWIWVWY
Golden Rule States Available

AKAL $40ARAZCA $32COCTDC $25DE $50FL $60GA $10HIIAIDILINKS $5KY $50/$120LA $30/$100MA $75MDME $45MIMNMOMSNC $22ND $10NE $8NH $25NJ $25NYNMNV $15OH $20OK $30ORPA $15RISCSD $20TN $15TX $10UTVA $7VT $60WA $20WI $30WV $25WY $15
Clover Health States Available*

ALAZGANJPASCTNTXMS
Globe Life & Accident States Available*

ILINKYNCOHPATN
Highmark States Available*

DENYPAWV
Kaiser States Available*

COGAORWA
Select Health States Available*

CONV
Kaiser CO License Number*
Kaiser CO License Status*
Kaiser CO License Issue Date*
Kaiser CO License Expiration Date*
Kaiser GA License Number*
Kaiser GA License Status*
Kaiser GA License Issue Date*
Kaiser GA License Expiration Date*
Kaiser OR License Number*
Kaiser OR License Status*
Kaiser OR License Issue Date*
Kaiser OR License Expiration Date*
Kaiser WA License Number*
Kaiser WA License Status*
Kaiser WA License Issue Date*
Kaiser WA License Expiration Date*
Resident License State-Required for SCAN*
Resident License Number-Required for SCAN*
License Expiration Date-Required for SCAN*
UHC States Available - We will only process your resident state. If you wish to add more states, please reach out to your marketer once you obtain a writing number*

AKAL $120ARAZCA $32COCT $250DC $75DE $200FL $300GA $40HIIA $66IDILINKS $25KY $150/$360LA $90/$300MA $300MDME $180MI $15MN $90MOMS $100MTNC $105ND $75NE $81NH $100NJ $100NYNM $80NV $60OH $50OK $150ORPA $90RI $75SCSD $60TN $75TX $60UTVA $35VT $240WA $80WI $60WV $75WY $45
United American States Available*

ALAZCACTDCDEFLGAIAIDINKSKYLAMAMEMIMNMSNCNDNENHNJNMNVOHOKORPASDTNTXVAVTWAWIWVWY
Washington National - Please mark the Products you would like to offer to your clients*

Active CareHospital SecureSolutions CancerPulse Protection SeriesCritical SolutionsAccident AssureGroup Critical IllnessGroup CancerGroup AccidentGroup Wage GuardGroup Worksite Critical IllnessLife OptionsWorksite UL2TermLife AssureProvidence
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 a copy of your AHIP Certificate before a contracting link can be sent out. Please be sure to upload this required document.
**Highmark requires 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.
Signature*

Clear
Complete this EFT form to receive commission from Premier. Please save and upload below*
Complete the W-9 to receive commissions from Premier. Please save and upload below*
Agent Agreement. Please complete, save and upload using the file upload option below.*
Complete this VectorOne document to receive advance commissions for Aflac (Tier One). Please save and upload below.*
This form below is required for the AR Blue Cross and Blue Shield appointment. Please save and upload below*
This form is required for a Blue Cross Blue Shield of Nebraska appointment. Please save and upload below*
This form below is required for the Baylor Scott & White appointment. Please save and upload below*
For Florida Blue, if you are LOA, please be sure you and your upline both sign this document. You will be the Assignor, and your immediate upline will be the Assignee
Highmark AOC Form
ManhattanLife Assurance Company (DVH) required this document to be submitted if you are requesting advance commissions. Please complete and upload below.*
This form below is required for your People's Health appointment. Please save and upload below*
Physicians Mutual state appointment fee chart for your reference.
Sonder Health Certification & Contracting Info
Premier Companies AOC Form
Form Completed By:*
File upload

One or more of the carriers you requested requires additional documentation. Please attach additional required forms such as EFT, Voided Check, W9, or carrier required documents as indicated in the field(s) above.
Cancelof
Should be Empty:

Health Carrier Contract Request Form

Agent Information

Agency Information

Contract Information