Producer Information Form

Producer Information Form
New/Existing Agent*
I am requesting to be appointed as an:*

AgencyIndividualBoth
Name (as it appears on your license)*

First NameLast Name
Preferred / Nick Name
Date of Birth

MonthDayYear
Date
National Producer Number (NPN)*

Contact/Contract Info
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Carrier Selections*

Aetna/SilverscriptAetna Senior SupplementAflacAllstate - Med SuppAmeritasAnthemAnthem Empire (NY)BCBS (IL)BCBS (NC)BCBS (RI)BCBS (SC)BCBS (TN)CapitalBlue (PA)CareFirst - Med Advantage (MD)CareFirst - Med Supp (DC / MD / VA)CarePartners of ConnecticutCigna Healthspring (MAPD Only - PDP Not Available)Cigna Medicare SupplementClear SpringClover HealthCommonwealth Care Alliance (MA / RI)Connecticare (CT)DevotedEmblem HealtheternalHealth (MA)Fallon Health (MA)Florida BlueGateway (PA)Geisinger (PA)Gerber LifeGuarantee Trust LifeHarvard Pilgrim Healthcare - Med Advantage (NH Only)Harvard Pilgrim Healthcare - Med Supp (MA / ME / NH)HealthFirst (NY)Health New England (MA)Highmark (PA / WV)HumanaIndependence Blue CrossKaiser Permanente (MD / VA)Lasso HealthcareMass Advantage-Central Mass Health (MA)Mass General BringhamMedical Mutual of OhioMedicoMedigoldMolinaMutual of Omaha (Supplement/PDP)Physicians MutualPremier Senior Health PlanSCAN Health Plan (AZ / CA / NV)TuftsUnited AmericanUnitedHealthcare® Medicare SolutionsWellCareWoodmen Life
Aetna/Silverscript:

Select if transferring existing contract with Aetna
Anthem/Empire:

Select if transferring existing contract with Anthem/Empire
Social Security Number - Required by Anthem
Humana:

Select if transferring existing contract with Humana
UnitedHealthcare:

Select if transferring existing contract with UnitedHealthcare
WellCare:

Select if transferring existing contract with WellCare
Appointment State(s):
License(s)*

Cancelof
General Agent/Direct Upline*
Name of Person Completing Form

First NameLast Name
Should be Empty: