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 Insurance Marketing.

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 Insurance Marketing.

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 Insurance Marketing.

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 Insurance Marketing.

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 Insurance Marketing.

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 Insurance Marketing.

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

WellCare contract is active with Alpha Insurance Marketing.

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 Cigna?

Yes

Are you currently contracted with Scan? *

Yes

Scan Active Contract Status

Scan contract is active with Alpha Insurance Marketing.

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:

Select any additional local or regional MAPD Carriers you would like to contract with (these contracts will come from agent pipeline and not IFG)(select all that apply)

Would you like to get contracted for life insurance products? *

Select the life carriers you would like to contract with (select all that apply)

Is the agent currently appointed under another IMO with any of the Life carriers you selected above?

Would you like to contract for Affordable Care Act Plans? (ACA/Under 65 Health Insurance)

Please select any ACA carriers you are currently contracted with another upline and may need a release.

Select all ACA carriers you would like to contract with

Do you need access to the Alpha CRM? *

Do you need Health Sherpa Access? *

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

Signature

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