Home
Medicare Eligibles
Medicare Solutions
About Us
Careers With MedicareCU
Contracting
Contact
Credit Union Contact
801-702-8676
Home
Medicare Eligibles
Medicare Solutions
About Us
Careers With MedicareCU
Contracting
Contact
Credit Union Contact
801-702-8676
Contracting
Step
1
of
3
33%
To get started, please fill out the forms included with this cover page and fax or email them back to us with these additional documents: + Copy of your insurance license. Also any non-resident licenses for states in which you plan on selling. If you are contracting as a business entity rather than individual, please include your business license as well.
Copy of your E and 0
Copy of a voided check for direct deposit
Copy of proof anti-money laundering training (if you are selling life or financial products)
Copy of written explanation for any background issues
Copy of CE training certificate (if required in your state)
If you have any questions, please call 855.378.1451. Thank you! Again, we look forward to partnering with you and helping you increase production.
First Name
*
Last Name
*
Social Security No.
*
Gender
*
Male
Female
Birth Date:
*
MM slash DD slash YYYY
Email
*
Resident Insurance License # and State:
*
NPN:
*
Personal Name of Principal:
*
First
Last
Phone #:
*
FAX #:
Driver's License Number
*
DL State
*
Current Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Previous Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Please add your previous address is you have not lived in your current address for at least 7 years.
Mailing Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Doing Business As:
*
Individual
Business Entity
Solicitor/LOA
If DBA Solicitor/LOA list who you are assigning comissions to:
EIN:
*
Business Name:
*
Website:
Title:
Phone #:
*
Principal Name:
*
Principal Title:
Email:
*
Company Type
*
Corporation
Partnership
LLC
LLP
Corporation Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Beneficiary full name
*
Beneficiary Phone number
*
please list the number of the
Legal Questions for Contracting and Appointment Requests
1. Have you ever been charged or convicted of or plead guilty or no contest to any Felony, Misdemeanor, federal/state insurance and/or securities or investments regulations and statutes? Have you ever been on probation?
*
Yes
No
If Yes, Explain:
*
1-A. Have you ever been convicted of or plead guilty or no contest to any Felony?
*
Yes
No
If Yes, Explain:
*
1-B. Have you ever been convicted of or plead guilty or no contest to any Misdemeanor?
*
Yes
No
If Yes, Explain:
*
1-C. Have you ever been convicted of or plead guilty or no contest to a violation of federal or state securities or investment related regulation?
*
Yes
No
If Yes, Explain:
*
1-D. Have you ever been convicted of or plead guilty or no contest to a violation of state insurance department regulation or statute?
*
Yes
No
If Yes, Explain:
*
1-E. Has any foreign government, court, regulatory agency, or exchange ever entered an order against you related to investments or fraud?
*
Yes
No
If Yes, Explain:
*
1-F. Have you ever been charged with any Felony?
*
Yes
No
If Yes, Explain:
*
1-G. Have you ever been charged with any Misdemeanor?
*
Yes
No
If Yes, Explain
*
1-H. Have you ever been on probation?
*
Yes
No
If Yes, Explain:
*
2. Have you ever been or are you currently being investigated, have any pending indictments, lawsuits, or have you ever been in lawsuit with insurance company?
*
Yes
No
If Yes Explain:
*
2-A. Have you been under investigation by any insurance company?
*
Yes
No
If Yes, Explain:
*
2-B. Are you currently under investigation by any legal or regulatory authority?
*
Yes
No
If yes, explain:
*
2-C. Have you ever been or are you currently involved in any pending indictments, lawsuits, civil judgments or other legal proceedings (civil or criminal)(you may omit family court)
*
Yes
No
If Yes, Explain:
*
2-D. Have you ever been named as a defendant or co-defendant in a lawsuit, or have you ever sued or been sued by an insurance company?
*
Yes
No
If yes, explain:
*
3. Have you ever been alleged to have engaged in any fraud?
*
Yes
No
If Yes, Explain:
*
4. Have you ever been found to have engaged in any fraud?
*
Yes
No
If Yes, Explain:
*
5. Has any insurance or financial services company, or broker-dealer terminated your contract or appointment or permitted you to resign for reason other than lack of sales?
*
Yes
No
If Yes, explain:
*
5-A. Were you terminated/resigned because you were accused of violating insurance or investment related statutes, regulations, rules or industry standards of conduct?
*
Yes
No
If Yes, Explain:
*
5-B. Were you terminated/resigned because you were accused of fraud or the wrongful taking of property?
*
Yes
No
If Yes, explain:
*
5-C. Failure to supervise in connection with insurance or investment related statutes, regulations, rules or industry standards of conduct?
*
Yes
No
If Yes, Explain:
*
6. Have you ever had an appointment with any insurance company terminated for cause or been denied an appointment?
*
Yes
No
If Yes, Explain:
*
7. Does any insurer, insured, or other person claim any commission chargeback or other indebtedness from you as a result of any insurance transactions or business?
*
Yes
No
If Yes, Explain:
*
8. Has any lawsuit or claim ever been made against your surety company, or errors and omissions insurer, arising out of your sales or practices, or, have you been refused surety bonding or E&O coverage?
*
Yes
No
If Yes, Explain:
*
8-A. Has a bonding or surety company ever denied, paid on or revoked a bond for you? Or, have you ever had a claim filed against your surety company?
*
Yes
No
If Yes, Explain:
*
8-B. Has any Errors & Omissions (E&O) carrier ever denied, paid claims on or cancelled your coverage? Or, have you ever had a claim filed against your E&O carrier?
Yes
No
If Yes, Explain:
*
9. Have you ever had an insurance or securities license denied, suspended, cancelled or revoked?
*
Yes
No
If Yes, Explain:
*
10. Has any state or federal regulatory body found you to have been a cause of an investment OR insurance-related business having its authorization to do business denied, suspended, revoked, or restricted?
*
Yes
No
If Yes, Explain:
*
11. Has any state or federal regulatory agency revoked or suspended your license as an attorney, accountant, or federal contractor?
*
Yes
No
If Yes, Explain
*
12. Has any state or federal regulatory agency found you to have made a false statement or omission or been dishonest, unfair, or unethical?
*
Yes
No
If Yes, Explain:
*
13. Have you ever had any interruptions in licensing?
*
Yes
No
If Yes, Explain:
*
14. Has any state, federal or self-regulatory agency filed a complaint against you, fined, sanctioned, censured, penalized or otherwise disciplined you for a violation of their regulations or state or federal statutes? Have you ever been the subject of a consumer initiated complaint?
*
Yes
No
If Yes, Explain:
*
14-A. Has any regulatory body ever sanctioned, censured, penalized or otherwise disciplined you?
*
Yes
No
If Yes, Explain:
*
14-B. Has any state, federal or self-regulatory agency filed a complaint against you, fined or sanctioned you? Yes No
*
Yes
No
If Yes, Explain:
*
14-C. Have you ever been the subject of a consumer initiated complaint?
*
Yes
No
If Yes, Explain:
*
15. Have you personally or any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or declared bankruptcy?
*
Yes
No
If Yes, Explain:
*
15-A. Have you personally filed a bankruptcy petition or declared bankruptcy?
*
Yes
No
If Yes, What was the amount?
*
15-B. Has any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or been declared bankrupt either during your association or within five years after termination of such association?
*
Yes
No
If Yes, Explain:
*
15-C. Is the bankruptcy pending?
*
Yes
No
If Yes, please provide the date of the Bankruptcy:
*
16. Have you ever had any judgments, garnishments, or liens against you?
*
Yes
No
If Yes, Explain:
*
17. Are you connected in any way with a bank, savings & loan association, or other lending or financial institution?
*
Yes
No
If Yes, Explain:
*
18. Have you ever used any other names or aliases?
*
Yes
No
List all other names or aliases
*
19. Do you have any unresolved matters pending with the Internal Revenue Service or other taxing authority?
*
Yes
No
If Yes, Explain:
*
I hereby authorize MedicareCU to affix or append a facsimile of my signature, as set forth below, to all required signature fields on all Insurance Carrier documents for which I have authorized MedicareCU to submit on my behalf, for the purpose of being Contracted to sell products of Carriers through MedicareCU. I affirm that the information have submitted through the interview process to MedicareCU is correct to the best of my knowledge and acknowledge that I have read and reviewed the documents for which I am authorizing my signature to be affixed to. I acknowledge and agree to indemnify and hold harmless and third party form and against and and all loss arising out of its reliance and acceptance of a facsimile of my signature. By signing this form, I acknowledge that all information is true and correct to the best of my knowledge.
*
By signing your name electronically on this form, you are agreeing that your electronic signature is the legal equivalent of your manual signature on this form.
Other Information (optional)
Have you taken an AML (Anti Money Laundering) course within the past two years?
*
Yes
No
If Yes, Date of AML (Anti Money Laundering)
*
MM slash DD slash YYYY
Course Name:.
*
Long Term Care Partnership certification: please attach certificate or CE update
Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.
Please Select Your Carriers by Checking the Boxes Below
*
Aetna Medicare Advantage
Aetna Senior Products (Med Supp)
Anthem
ARLIC/CHLIC (Cigna) Med Supp
Bankers Fidelity Med Supp
Cigna HealthSpring
Humana
Molina
Mutual of Omaha MA/PDP
Mutual of Omaha Med Supp
SilverScript
Thrivent Med Supp
Transpremier Med Supp
UnitedHealthcare (UHC)
Wellcare Medicare Advantage/PDP
American General Life (AIG) Life, Annuity, FE
Athene (Life & Annuity)
F&G (Life & Annuity)
Guarantee Trust Life (GTL) Life
John Hancock (Life & Annuity)
Lincoln Financial (Life & Annuity)
Mutual of Omaha (Life, Annuity, FE, LTC)
North American (Life & Annuity)
Protective (Life & Annuity)
Transpremier (Life & FE)
Washington National (Life & Annuity)
Allianz (Life & Annuity)
American Equity (Life & Annuity)
Americo (Life, Annuity, FE)
Banker's Fidelity (Life & Annuity)
Banner Life (Life & Annuity) Life Only
Cigna Final Expense
EquiTrust (Life & Annuity)
Great Western (FE)
Loyal American (Cigna) FE
United Home Life (Life & FE)
William Penn (NY Only - used in place of Banner Life) Life Only
Please select at least 3 Competitive MA carriers to be eligible for our full support/ leads program. (UHC, Aetna, Humana)
I hereby authorize MedicareCU to affix or append a facsimile of my signature, as set forth below, to all required signature fields on all Insurance Carrier documents for which I have authorized MedicareCU to submit on my behalf, for the purpose of being Contracted to sell products of Carriers through MedicareCU. I affirm that the information have submitted through the interview process to MedicareCU is correct to the best of my knowledge and acknowledge that I have read and reviewed the documents for which I am authorizing my signature to be affixed to. I acknowledge and agree to indemnify and hold harmless and third party form and against and and all loss arising out of its reliance and acceptance of a facsimile of my signature. By signing this form, I acknowledge that all information is true and correct to the best of my knowledge.
*
By signing your name electronically on this form, you are agreeing that your electronic signature is the legal equivalent of your manual signature on this form.
Insurance Licenses
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.
Individual and Business. If licensing as a business entity, you must include both individual and business licenses for each state you are contracted in.
E&O
*
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.
Errors and Omissions (E&O)
Banking Information
This site is secure. Your information will be transmitted securely via SSL.
Requesting Commission Advancing?
*
Yes
No
Account Owner Name:
*
Routing Number
*
Account Number
*
Branch Name
*
Branch Address
*
Account Type:
*
Checking
Savings
Money Market
BE SURE TO ATTACH A VOIDED CHECK
*
Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.
I hereby authorize MedicareCU to affix or append a facsimile of my signature, as set forth below, to all required signature fields on all Insurance Carrier documents for which I have authorized MedicareCU to submit on my behalf, for the purpose of being Contracted to sell products of Carriers through MedicareCU. I affirm that the information have submitted through the interview process to MedicareCU is correct to the best of my knowledge and acknowledge that I have read and reviewed the documents for which I am authorizing my signature to be affixed to. I acknowledge and agree to indemnify and hold harmless and third party form and against and and all loss arising out of its reliance and acceptance of a facsimile of my signature. By signing this form, I acknowledge that all information is true and correct to the best of my knowledge.
*
By signing your name electronically on this form, you are agreeing that your electronic signature is the legal equivalent of your manual signature on this form.
