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Agent Application

First Name (as shown in the DOI)

Last Name (as shown in the DOI)

Birthday

National Producer Number (NPN)

Phone

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Email

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DOI

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What lines of business do you want to Contracted?

Medicare

ACA

Life & Annuities

Anxiliares

Medicare Contracts:

Humana/Careplus (Popular)

Simply (Popular)

Devoted (Popular)

Wellcare/Centene (Popular)

United HealthCare (Popular)

Cigna

Aetna (Popular)

Freedom/Optimum (Popular)

Florida Blue

Ultimate

Health Sun

Solis

Gold Kidney

All Medicare Carriers

ACA Products:

Aetna

Amerihealth (FL, NC, SC, DE)

Ambetter

Anthem BCBS (CO, CT, CA, GA, IN, ME, OH, VA, WI, KY, MO, NV, NH)

AvMed (FL)

CareSource (IN, NC, GA, KY, OH, WV)

Christus (TX & LA)

Cigna (FL, GA, MS, AZ, IL, UT, CO, NC,TN, VA,IN, PA, SC, TX)

Highmark (DE, WV, PA)

Molina (SC, UT, CA, IL, WA, MI, OH, WI, FL , TX, ID, NM, KY, MS)

Oscar (OH, TN, VA, NJ, AZ, IA, KS, MI, MO, NE, OK, PA, FL, GA, IL, NC, TX)

United HealthCare (FL, SC, IL, GA, LA, NC, OH, TX, AL, AZ, CO, KS, MD, MI, MO, MS, NJ, NM, OK, TN, VA, WI, WA)

FFM User

Anxiliares:

Ameritas Dental & Vision

Washington National

United Health One

Aetna- Complementary

Life Products:

Ameritas Life

Americo

Gerber

Great Western

United Of Omaha (Mutual Of Omaha)

National Life

Driver License

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