New Agent Contracting Request Form

Thank you for your interest in contracting with Axxess Benefit Consultants. Please complete the below form so that we can get your contracting started for you today!

First Name *

Last Name *

DOB *

SSN *

Address *

City, State, Zip *

Phone *

Email *

Referred by *

Agent NPN (National Producer Number) *

Resident Agent License Number *

Resident State *

Agent License Expiration Date *

Do you have any non-resident licenses? *

Agency Name

Agency Tax ID/EIN

Agency NPN #

Agency License Number

E&O Insurance Carrier

What is your E&O policy limit?

Are you currently employed as a captive agent? *

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 that you selected above?

Please select the life insurance carriers 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 supplemental health carriers you are requesting (Med Supp, DVH, Critical Illness, etc.)

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?

Are you FFM certified to sell ACA products? *You must be FFM certified before carriers process your ACA contract requests.

Please select the ACA carriers you are requesting

Requested ACA certified non-resident state appointments

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

Are you currently contracted with any of the ACA carriers above?

Team Builder

Immediate Upline

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

Do we have permission to use your photograph on our website and social media platforms? *

Would you like to be added to the Axxess group chat? (for access to opportunities and updates) *