Medicare Advantage Appointment Request Form
Personal Information
First Name
*
Last Name
*
Phone
*
Email
*
Address
*
City
*
State
*
Postal code
*
Date of birth
*
National Producer #
*
Social Security #
*
Resident State Insurance License #
*
Will you be requesting to have your licensed Business Entity (Agency) appointed?
*
Will you be requesting to have your licensed Business Entity (Agency) appointed?
Yes
No
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Medicare Advantage Appointment Request Form
Business Entity (Agency) Information
Licensed Business Entity Name (Agency Name)
*
Business Entity Address (Agency)
*
Business Entity City (Agency)
*
Business Entity State (Agency)
*
Business Entity State (Agency)
AL
AK
AZ
AR
CA
CO
CT
DE
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
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Business Entity Postal Code (Agency)
*
Business Entity National Producer Number (Agency)
*
Business Entity Tax EIN# (Agency)
*
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Medicare Advantage Appointment Request Form
Appointment Info
Immediate Upline
*
Managing Upline
*
Carriers Available: AETNA, Cigna, UHC, Humana, and Wellcare
If you are currently contracted with any carrier from the list above, be sure to submit you immediate release with this request form. If you are unable to get the immediate release, please let us know, and we will go over the delayed release process for each carrier.
You will be sent a welcome email with instructions for each carrier.
Certifications are required before contracts will be processed and you are issued a writing number.
Appointment Requests will be delayed if all of the above information is not completed.
To continue, please click on the blue "Play" button in the lower right-hand corner of the form.
Medicare Advantage Appointment Request Form
Will you be requesting a carrier contract/appointment with Cigna?
Will you be requesting a carrier contract/appointment with Cigna?
Yes
No
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Cigna Additional Info
Do you plan on assigning your commissions to an Agency?
*
Do you plan on assigning your commissions to an Agency?
Yes
No
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**If yes, please list the Agency Name
Will you be selling Cigna as a "Field Agent" or will you be based in a call center and selling as a "Telephonic Agent"?
*
Will you be selling Cigna as a "Field Agent" or will you be based in a call center and selling as a "Telephonic Agent"?
Field Agent
Telephonic Agent
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Please indicate the service area(s) in which you plan to sell Healthspring (please select all that apply): You must have a currently active state Health license in all of the states you chose below.
*
AL
AZ
AR
DC
CO
DE
FL
GA
IL
KS
MD
MS
NO
NC
NJ
PA
SC
TN
TX
IN
If you are contracting with Cigna as an Agency does the Principal of the organization plan on selling Healthspring on their personal pen?
If you are contracting with Cigna as an Agency does the Principal of the organization plan on selling Healthspring on their personal pen?
Yes
No
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Hierarchy Form
*
Agent Name:
GA Name:
MGA Name:
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Medicare Advantage Appointment Request Form
Will you be requesting a carrier contract/appointment with United Healthcare?
*
Will you be requesting a carrier contract/appointment with United Healthcare?
Yes
No
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United Healthcare Additional Info
UHC Contract Level
*
LOA
AGENT
GA
MGA
To continue, please click on the blue "Play" button in the lower right-hand corner of the form.
Medicare Advantage Appointment Request Form
Will you be requesting a carrier contract/appointment with Aetna?
*
Will you be requesting a carrier contract/appointment with Aetna?
Yes
No
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Aetna Additional Info
Aetna Contract Level
*
LOA
AGENT
GA
MGA
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Medicare Advantage Appointment Request Form
Will you be requesting a carrier contract/appointment with Humana?
Will you be requesting a carrier contract/appointment with Humana?
Yes
No
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Humana Additional Info
Humana Contract Level
*
LOA
AGENT
GA
MGA
To continue, please click on the blue "Play" button in the lower right-hand corner of the form.
Medicare Advantage Appointment Request Form
Will you be requesting a carrier contract/appointment with Wellcare?
Will you be requesting a carrier contract/appointment with Wellcare?
Yes
No
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Wellcare Additional Info
Wellcare Contract Level
*
LOA
AGENT
GA
MGA
To complete, please click on the blue "Submit" button in the lower right-hand corner of the form.
