Introduction

Thank you for considering Simple Choice Insurance Brokerage PLLC as a partner to help you grow your business. This process should not take longer than 10 minutes to complete your registration. Should you have any questions, please text, call or email us your questions.

Best Regards,
LaQuentin Jenkins
Managing Partner

Phone: (832) 626 7791
Email: contracting@simplechoiceib.com
Websites: https://www.simplechoiceib.com/agents

First Name

Last Name

Phone/Mobile

Look your NPN# here - https://nipr.com/help/look-up-your-npn

NPN #

Mailing Address

Address

Street Address

Apt/ Unit/ Suite

City

State

Zip Code

Credentials / Certifications

Do you have active Life, Health & Accident insurance license?

Yes

Do you have an E & O Insurance?

Yes

Please upload a copy of your 2022 AHIP if completed.

Choose File

Have you completed your 2021 FFM Certification?

Yes

Please upload a copy of your 2022 FFM Certification if completed. This certificate gives you the ability to sell health insurance on the marketplace.

Choose File

License Information

In which state do you have an active resident L H &A insurance license?

Upload copy of your resident state License.

Choose File

List any other states you have an active LH&A license.

Group Health Insurance

Are you interested in selling group health insurance?

Yes

Agent Referral Program

Are you interested in participating in our referral programs?

Please check all that apply.

Medicare Advantage - $100 per referral

Medicare Supplements - $50 per referral

Traditional Life Insurance - 70/30 Split No charge back repayment

Final Expense - 70/30 Split No charge back repayment

Long-Term Care/ Short Term Care - 70/30 Split No charge back repayment

Annuities - 70/30 Split No charge back repayment

ACA "Obamacare" - $25 per application

Agent Registration

Introduction

Mailing Address

Credentials / Certifications

License Information

Group Health Insurance

Individual Health Insurance

Agent Referral Program

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