Producer Information Form
New/Existing Agent
*
Please Select
New Agent Requesting Initial Contracts
New Agent Transferring Contracts
Existing Agent Adding Contracts
I am requesting to be appointed as an:
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Agency
Individual
Both
Individual/Solicitor
Corporation/Solicitor
Name (as it appears on your license)
*
First Name
Last Name
Preferred / Nick Name
Date of Birth
*
-
Month
-
Day
Year
Date
National Producer Number (NPN)
*
Agency Information
Agency Name:
Agency NPN:
Contact/Contract Info
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Carrier Selections
*
Aetna/Silverscript
Aetna Senior Supplement
Aflac
Allstate - Med Supp
Amerihealth (DE / FL / NJ / PA / SC)
Ameritas
Anthem
Anthem Empire (NY)
BCBS (IL)
BCBS (NC)
BCBS (RI)
BCBS (SC)
BCBS (TN)
BCBS (TX)
CapitalBlue (PA)
CareFirst - Med Advantage (MD)
CareFirst - Med Supp (DC / MD / VA)
CarePartners of Connecticut
Cigna Healthspring (MAPD/PDP)
Cigna Medicare Supplement
Clover Health
Commonwealth Care Alliance (MA / RI)
Connecticare (CT)
Devoted
Emblem Health
eternalHealth (MA)
Fallon Health (MA)
Florida Blue
Gateway (PA)
Geisinger (PA)
Gerber Life
Guarantee Trust Life
Harvard Pilgrim Healthcare - Med Advantage (NH Only)
Harvard Pilgrim Healthcare - Med Supp (MA / ME / NH)
HealthFirst (NY)
Health New England (MA)
Highmark (PA / WV)
Humana
Independence Blue Cross
Kaiser Permanente (MD / VA)
Lasso Healthcare
Manhattan Life
Mass Advantage-Central Mass Health (MA)
Mass General Bringham
Medical Mutual of Ohio
Medico
Medigold
Molina
Mutual of Omaha (Supplement/PDP)
Physicians Mutual
Premier Senior Health Plan
SCAN Health Plan (AZ / CA / NV)
Select Health (CO / ID / NV / UT)
Tufts
United American
UnitedHealthcare® Medicare Solutions
WellCare
Woodmen 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):
*
Alabama
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
License(s)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Have you completed AHIP for the current year?
*
Yes
No
AHIP Certificate
Browse Files
Drag and drop files here
Choose a file
Cancel
of
General Agent/Direct Upline
*
Please Select
Hilb Group Medicare, LLC
Brian Mumford
CJC Advisors/Salois
Daniel Byrne
Dupe8537/Dupuy
DeverCare Insurance
Eagle Insurance/Rahme
Effie Visoulis
Elizabeth Ley
Millszy's/Mills
Florinda Acosta
Isabel Ribeiro
Jeremy Jones
LR Wright/Rocky
MediPlan Advisors/Putrino
Medi Plus Benefit Group/Rolin
Michael Ferraro
Nichole Brown
Secure Benefits, LC
Sinapi Insurance
Tribundant/Brown
Name of Person Completing Form
First Name
Last Name
Submit
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