Agent Contracting

Personal Information

Enter your details exactly as they appear on your insurance license.

Full legal name (as shown on license) *

Date of birth *

Last 4 of SSN *

Your full SSN is collected securely during carrier onboarding, never on this form.

Home street address *

City *

State *

ZIP *

Mobile phone *

Email *

Contracting as *

Individual Agency / LLC

Entity name *

EIN *

Agency NPN *

Look it up at nipr.com if unsure.

Agency license number *

Licensing & Compliance

Your license, lines of authority, E&O, and AML details.

National Producer Number (NPN) *

Look yours up at nipr.com if unsure.

Resident license state *

License number *

Lines of authority you're requesting contracting for *

Medicare Life Long-Term Care Annuity

Non-resident states held (optional)

Non-resident states desired (optional)

Do you have an active E&O policy? *

Yes No

Carrier name *

Policy number *

Expiration date *

Coverage amount *

Most carriers require a minimum of $1M per occurrence.

No problem, you can still submit your transmittal. You'll need active E&O before carriers approve your appointments. NAPA offers agent E&O coverage with fast online enrollment.

Have you completed AML training? *

Yes No

Provider *

Need to look up or complete your AML certification? SuranceBay AML.

Completion date *

You can still submit. Many carriers accept free AML training, and SuranceBay offers a no-cost course that most of our carriers recognize.

Years of insurance experience *

Medicare Certifications

Your AHIP status and Medicare history.

AHIP certified for the current plan year? *

Yes No In progress

AHIP completion year *

Have you sold Medicare Advantage or PDP before? *

Yes No

Do you have current Medicare business in force? *

Yes No

Contracting Requests & Disclosures

Choose the carriers you want appointed with, then confirm your release status and disclosures.

Release status

Are you currently contracted with any of the requested carriers under another upline? *

Yes No

Which carriers? *

Current upline name *

Have you requested a release? *

Yes No Not sure

Why we ask about releases Open releases typically take 1 to 6 months depending on the carrier. Knowing your status upfront lets us route your contracting correctly and avoid delays.

Background disclosures

Carriers ask these questions during appointment. Answering accurately here prevents surprises and lets us advocate for you if anything needs context.

Have you ever been convicted of a felony or misdemeanor (other than minor traffic)? *

Yes No

Please explain *

Have you ever filed for bankruptcy or have outstanding liens or judgments? *

Yes No

Please explain *

Have you ever had an insurance license suspended, revoked, or been terminated for cause by a carrier? *

Yes No

Please explain *

Do you owe a debit balance to any insurance carrier or FMO? *

Yes No

Please explain *

Review & Submit

Double-check everything below. Use Edit to jump back to any section.

Documents to have ready Within one business day you'll receive onboarding next steps by email to complete your documents, banking, and SSN details. Depending on the carrier, that may be through SureLC or a direct carrier process.

Copy of resident license
E&O certificate
AML certificate
AHIP certificate
Voided check
W-9

I authorize TrustInsure and its FMO partners to process my contracting requests and conduct background verification as required by the requested carriers. I certify the information provided is accurate. *

Signature (type your full name) *

Date

Something went wrong submitting your transmittal. Your answers are still here. Email it to blake@trustinsuregroup.com instead, or try again.

Personal Information

Licensing & Compliance

Medicare Certifications

Contracting Requests & Disclosures

Medicare carriers

Life carriers

Long-Term Care carriers

Annuity carriers

Review & Submit

You're in the queue

We review your transmittal

We send your onboarding steps

Contracting submitted to carriers