Existing Agent Contracting Request Form

This form is for existing Axxess Benefit Consultants agents. Please complete the below form so that we can get these additional contracts started for you today!

First Name *

Last Name *

Email *

Agent NPN (National Producer Number) *

Agency Name

Agency NPN #

Please select the Medicare Advantage carriers you are requesting.

Please list any other Medicare Advantage carriers you'd like to contract with.

Are you currently contracted with any of the Medicare Advantage carriers above?

Please select the additional Life Insurance carrier(s) you are requesting.

Please list any other life carriers you'd like to contract with

Are you currently contracted with any of the Life Insurance carriers that you selected above?

Please select the additional supplemental health carriers you are requesting.

Please list any other supplemental health carriers you'd like to contract with

Are you currently contracted with any of the supplemental health carriers above?

Do you want to request contracting for ACA products? *

Request type *If you need both a new request AND a transfer request, please select 'New' and select the carriers in the dropdown below, then list any transfer requests in the subsequent field.

Please select your ACA Carriers *

Please list any other ACA carriers you'd like to contract with/need transfers for *

Team Builder *

Direct Upline *

Payee *If the agent will be assigning commissions to a Payee/Agency, please type the entity here.

Requested ACA certified state appointments *

SSN *

DOB *

Address *

Phone *