Legal First Name *

Full legal first name, exactly as it appears on your insurance license

Legal Middle Name

As shown on your license (leave blank if none)

Legal Last Name *

Must match your insurance license

Preferred Name

Email *

Mobile Phone *

Street Address *

City *

ZIP Code *

State *

Resident License State *

Resident License Number *

National Producer Number (NPN) *

Look it up free at nipr.com if you're not sure

Years Licensed *

Business Entity / Agency Name

Only if you contract through your own agency

Non-Resident States Currently Held

Select all that apply. We'll verify licenses online during onboarding.

AHIP Certified for this plan year? *

Yes

No

Any prior license actions, suspensions or complaints? *

Yes

No

If yes, please explain

Required if you answered Yes above

Medicare / AEP Experience *

Tell us about your Medicare sales experience

Telephone sales, carriers sold, typical volume, etc.

Previous Carriers / IMOs Appointed With

Carrier Contracts Requested

I want ALL available carrier contracts

Do you need releases from any current carriers or upline? *

Yes

No

If yes, list the carriers / upline

Copies of Releases

Upload any releases you already have

Resume

Resident License Copy *

E&O Certificate

E&O coverage is required before we can submit your contracts. If you don't have it yet, you'll need to buy a policy first. Individual-agent E&O is available from CalSurance.

Do you own a computer? *

Yes

No

Do you have reliable high-speed internet? *

Yes

No

Do you have a headset? *

Yes

No

Do you have a quiet, dedicated workspace? *

Yes

No

Earliest Start Date *

Availability *

How did you hear about us?

Agreement *

I agree that America's Trusted Benefits may contact me about this application.