CAG COM IB IAG CHA Individual Broker AgreementIndividual Broker Agreement • March 9th, 2010
HEAD OF AGENCY FULL NAME AGENCY NAME FEDERAL TAX I.D. NUMBER or SSN AGENCY ADDRESS CITY/STATE /ZIP CODE AGENCY TELEPHONE FAX NUMBER COUNTY AGENT HOME ADDRESS CITY/STATE /ZIP CODE HOME TELEPHONE FAX NUMBER E-MAIL ADDRESS (Unique & REQUIRED) DATE OF BIRTH The Field Marketing Organization (FMO) that I will be conducting future Medica IFB & Medicare business with is Sunderland Group . I understand that I will be assigned to theabove-referenced FMO hierarchy for Medica IFB & Medicare business only. Type of product you want to sell: Individual Business Medicare Individual Medicare Group Date: X SIGNATURE OF AGENT APPOINTING
Individual Broker Agreement IAG COM Corporate Agency Agreement CAG COM Provisional Broker Agreement IAG PRVIndividual Broker Agreement • April 3rd, 2017 • Minnesota
AGENT FULL NAME(Last, First, Middle) DATE OF BIRTH/ / SOCIAL SECURITY NUMBER - - # MALE # FEMALE HEALTH INSURANCE LICENSE NUMBER MN WI ND SD Please attach copy of applicable license(s) (REQUIRED) NPN: AGENCY NAME FEDERAL TAX I.D. NUMBER AGENCY ADDRESS CITY/STATE /ZIP CODE AGENCY TELEPHONE FAX NUMBER COUNTY AGENT HOME ADDRESS CITY/STATE /ZIP CODE HOME TELEPHONE FAX NUMBER E-MAIL ADDRESS (Unique & REQUIRED) Send mail to (check one only): □.Agency address □.Home address □ Other - Please provide to Medica 1. Have you ever been convicted of a felony under state or federal law, or a crime involving dishonesty or breach of trust? □.Yes □.No2. Has any insurance disciplinary action ever been taken against you? □.Yes □.NoIf yes to either question, please provide dates, explain, and attach documentation: Errors & Omissions Insurance Carrier(REQUIRED) Level (amount) Exp. date Please attach copy of declaration page Policy Number Held by: # Self # Agency Assign commissions to: #. Agent #
Individual Broker Agreement IAG COM Corporate Agency Agreement CAG COM Provisional Broker Agreement IAG PRVIndividual Broker Agreement • March 9th, 2010
AGENT FULL NAME(Last, First, Middle) DATE OF BIRTH/ / SOCIAL SECURITY NUMBER - - # MALE # FEMALE HEALTH INSURANCE LICENSE NUMBER MN WI ND SD Please attach copy of applicable license(s) (REQUIRED) NPN: AGENCY NAME FEDERAL TAX I.D. NUMBER AGENCY ADDRESS CITY/STATE /ZIP CODE AGENCY TELEPHONE FAX NUMBER COUNTY AGENT HOME ADDRESS CIITY/STATE /ZIP CODE HOME TELEPHONE FAX NUMBER E-MAIL ADDRESS (Unique & REQUIRED) 1. Have you ever been convicted of a felony under state or federal law, or a crime involving dishonesty or breach of trust? □.Yes □.No2. Has any insurance disciplinary action ever been taken against you? □.Yes □.NoIf yes to either question, please provide dates, explain, and attach documentation: Errors & Omissions Insurance Carrier(REQUIRED) Level (amount) Exp. date Please attach copy of declaration page Policy Number Held by: # Self # Agency Type of Product you wish to sell: □ Individual Business □ Medicare Individual □ Medicare Group Agreement type: □ Preferred □ Full Mem
CAG COM IB IAG CHA Individual Broker AgreementIndividual Broker Agreement • March 9th, 2010
HEAD OF AGENCY FULL NAME AGENCY NAME FEDERAL TAX I.D. NUMBER AGENCY ADDRESS CITY/STATE /ZIP CODE AGENCY TELEPHONE FAX NUMBER COUNTY AGENT HOME ADDRESS CITY/STATE /ZIP CODE HOME TELEPHONE FAX NUMBER E-MAIL ADDRESS (Unique & REQUIRED) The Field Marketing Organization (FMO) that I will be conducting future Medica IFB & Medicare business with is Agent Pipeline, Inc. . I understand that I will be assigned to the above-referenced FMO hierarchy for Medica IFB & Medicare business only. Type of product you want to sell: Individual Business Medicare Individual Medicare Group Date: X SIGNATURE OF AGENT APPOINTING
CAG COM IB IAG CHA Individual Broker AgreementIndividual Broker Agreement • March 9th, 2010
HEAD OF AGENCY FULL NAME AGENCY NAME FEDERAL TAX I.D. NUMBER AGENCY ADDRESS CITY/STATE /ZIP CODE AGENCY TELEPHONE FAX NUMBER COUNTY AGENT HOME ADDRESS CITY/STATE /ZIP CODE HOME TELEPHONE FAX NUMBER E-MAIL ADDRESS (Unique & REQUIRED) The Field Marketing Organization (FMO) that I will be conducting future Medica IFB & Medicare business with is . I understand that I will be assigned to the above-referenced FMO hierarchy for Medica IFB & Medicare business only. Type of product you want to sell: Individual Business Medicare Individual Medicare Group Date: X SIGNATURE OF AGENT APPOINTING
