First Name
*
Last Name
*
Personal Phone (not office line)
*
Email
*
Address
*
City
*
State
*
Postal code
*
Date of birth
*
NPN
*
SSN #
*
Resident License #
*
AHIP Certified
*
YES
NO
Carriers you'd like to contracting with for Medicare Advantage?
*
Carriers you'd like to contract with for Medicare Supplement
Carriers you'd like to contract with for Medicare Supplement
Are You Currently Contracted With Any Carriers? ( please list all active contracts )
Upline Agency
*
None
RSM Brokers
RSM Newnan Office
BKZ - Senior Benefit Solution Metter Office
MNR - Better Place Tavares Office
MKZ - Nu Life Healthcare Office
KRZ - Better Place Lakeland Office
FKZ- Forsythe Healthcare Solutions Office
JKZ - Costal Senior Management Office
Alex Real Brokers
Benji Crooms - Brokers
Chris Forsythe Brokers
Dustin Futch Brokers
Josh Underwood - Brokers
Veronique Duperval
Lou Sauer Brokers
Martin Knustgraichen Brokers
Ryan Travers Brokers
USB- Jamey Motes & Eric Smith Brokers
Niche Market Insurers Agency Inc w/Benji
Reidenouer Insurance Services w/Benji
Dustin Futch LOA/Office
AiHealth w/ Jack McDonough
Marsh Insurance Corp. (BRIAN MARSH LLC)
James (Dave) Molitierno - Brokers
James (Dave) Molitierno - Agency LOA
Assured Life Solutions Brady Mundy
Lone Star Medicare Center Agency (Chris Smith)
Mondragon Corp
Veronique Duperval
BMBP - LOA
Avid Health
LC Financial Group
Diamond Financial Group
Upline Manager
Upline Manager
LOA or Broker
Do you have an LLC?
*
Yes (if so, email
[email protected]
with your business EIN, legal business name, and the business NPN)
No
Submit
