Type of Contracting Request

Team *

Sex *

Shirt Size *

Social Security Number *

National Producer Number *

Resident State License Number *

Resident License State *

All States Broker is Licensed In

Broker Language's (Select all that apply)

Do you own an agency? *

Agency Name (Optional)

Agency Website (Optional)

Agency NPN (Optional)

Agency FIN (Optional)

Agency License Number (Optional)

Are you currently contracted with Humana? *

Yes

Humana Active Contract Status

Humana contract is active with Alpha/IFG.

Humana contract is active with another FMO and the release process needs to be initiated.

Humana contract is active but I do not know the status.

Do you want to get contracted with Humana?

Yes

Are you currently contracted with UHC? *

Yes

UHC Active Contract Status

UHC contract is active with Alpha/IFG.

UHC contract is active with another FMO and the release process needs to be initiated.

UHC contract is active but I do not know the status.

Do you want to get contracted with UHC?

Yes

Are you currently contracted with WellCare? *

Yes

WellCare Active Contract Status

WellCare contract is active with Alpha/IFG.

WellCare contract is active with another FMO and the release process needs to be initiated.

WellCare contract is active but I do not know the status.

Do you want to get contracted with WellCare?

Yes

Are you currently contracted with Anthem/Amerigroup? *

Yes

Anthem/Amerigroup Active Contract Status

Anthem/Amerigroup contract is active with Alpha/IFG.

Anthem/Amerigroup contract is active with another FMO and the release process needs to be initiated.

Anthem/Amerigroup contract is active but I do not know the status.

Do you want to get contracted with Anthem/Amerigroup?

Yes

What states do you want to be contracted in for Anthem/Amerigroup?

Are you currently contracted with Aetna? *

Yes

Aetna Active Contract Status

Aetna contract is active with Alpha/IFG.

Aetna contract is active with another FMO and the release process needs to be initiated.

Aetna contract is active but I do not know the status.

Do you want to get contracted with Aetna?

Yes

Are you currently contracted with Devoted? *

Yes

Devoted Active Contract Status

Devoted contract is active with Alpha/IFG.

Devoted contract is active with another FMO and the release process needs to be initiated.

Devoted contract is active but I do not know the status.

Do you want to get contracted with Devoted?

Yes

Are you currently contracted with Cigna? *

Yes

Cigna Active Contract Status

Cigna contract is active with Alpha/IFG.

Cigna contract is active with another FMO and the release process needs to be initiated.

Cigna contract is active but I do not know the status.

Do you want to get contracted with Cigna?

Yes

Are you currently contracted with Scan? *

Yes

Scan Active Contract Status

Scan contract is active with Alpha/IFG

Scan contract is active with another FMO and the release process needs to be initiated.

Scan contract is active but I do not know the status.

Do you want to get contracted with Scan?

Yes

Please select any local IFG Carrier you would like to contract with:

Do you need access to the Alpha CRM? *

Do you have access to Sunfire? *

We provide E & O insurance is this something you are interested in?

Brokers E & O (Optional)

Brokers E & O

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