Alpha - Contracting - Existing Agent Contracting Request Form
Team
Team
Alpha
Robinson Insurance Group
Arizona Medicare Helpers
Sunshine Senior Services
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First Name
*
Last Name
*
Cell Phone
*
Email
*
Address
*
City
*
State
*
Postal code
*
Date of birth
*
Social Security Number
*
National Producer Number
*
Resident State License Number
*
Resident License State
*
Broker's Resident License State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
FL
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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All States Broker is Licensed In
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Are you currently contracted with UHC?
*
Yes
No
Are you currently contracted with WellCare?
*
Yes
No
Do you want to get contracted with WellCare?
Yes
No
Do you want to get contracted with Anthem/Amerigroup?
Yes
No
What states do you want to be contracted in for Anthem/Amerigroup?
AZ
CA
CO
CT
FL - Simply
GA
IA
IN
IL - Contract will say Agent Pipeline Instead of IFG
KY
LA
ME
MO
NJ
NH
NM
OH
NV
TX
VA
WA
WI
Do you want to get contracted with Aetna?
Yes
No
Do you want to get contracted with Devoted?
Yes
No
Do you want to get contracted with Cigna?
Yes
No
Do you want to get contracted with Scan?
Yes
No
Please select any local IFG Carrier you would like to contract with:
Geisinger (PA Only)
HighMark (PA, WV, & DE Only)
Independence Blue Cross (PA)
Molina (AZ, CA, ID, KY, MA, MI, NM, NY, OH, SC, TX, UT, VA, WA, WI)
UPMC (PA)
Clover (AL, GA, MI,NJ, PA, SC, TN, TX (AZ only in 1 county))
Capital Blue Cross (PA)
Zing Health (IL, IN, & MI Only)
Alterwood (MD)
Horizon: BCBS of NJ (NJ)
Alignment (AZ, CA, FL, NV, NC, TX)
Health Partners (PA)
Freedom/Optimum (FL)
Keyston VIP (PA)
Scan (CA AZ NM NV TX)
Alignment (AZ, CA, FL, NV, NC, TX)
Essence
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Signature
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