STEP 1: Creating Your Agent File

Create your Agent File by completing the information below. Please note that this is NOT your request for carrier contracts. Your request for carrier contracts are completed in Step 2.

Before you begin you will need the following items:
- A copy of your state insurance license(s)
- A copy of your E&O coverage
- A copy of your AHIP certification
Please complete ALL fields with a red *. If all items are not completed the contracting will not be processed.

Full Name *

SSN *

Date of birth *

Gender *

Male

Female

Phone *

Email *

Address *

City *

State *

Country *

Postal code *

County *

Have you lived at any other address in the last 2 years? *

Yes

Previous Address 1

Previous Start Date 1

Previous End Date 1

Previous Address 2

Previous Start Date 2

Previous End Date 2

Agent National Producer Number (NPN) *

NPN Lookup: https://nipr.com/help/look-up-your-npn

Resident License # *

Please attach a copy of your Insurance License(s) *

Please attach a copy of your E&O Insurance Certificate *

Please attach a copy of your AHIP Certification (if already completed) *

Please attach a copy of a Voided Check (for carrier deposits) *

*****Moving From Another Upline? CLICK HERE (NEED TO RECREATE) for Carrier Release Guidelines and Blackout Dates.*******

Please attach a copy of any Release Letters from Previous Uplines (if applicable) *

Are you contracting as a business entity? *

Yes

IMPORTANT NOTE:

If you are contracting as a business entity you MUST select "I'm contracting as an agency" when requesting your carrier contracts. This will ensure that you receive an agency onboarding link. Not doing so can delay the processing of your carrier contracts. You will also need to complete the business entity information on your W-9 where required.

Agency Name (if contracting as a business entity)

Agency Address (if contracting as a business entity)

Agency City

Agency State / Province

Agency Postal / Zip Code

Tax ID # (if contracting as a business entity)

Agency NPN # (if contracting as a business entity)

By clicking the submit button, I agree to terms & conditions. *

I agree

Elite Life Agency respects your privacy and takes protecting it seriously. This Privacy Policy covers our collection, use and disclosure of information we collect through our website and service. The use of information collected through our service shall be limited to the purpose of providing the service for which the Client has engaged Elite Life Agency. Your account information is held in strict confidence.

Signature

Clear

The contracting process for Medicare Advantage Carriers can take up to 3 weeks from the date the contract is submitted. Certifications are required BEFORE contracts will be processed and you are issued a writing number.

Appointment requests will be delayed if all of the above information is NOT completed.