Simple Choice -- Contracting Form

Welcome to Simple Choice and our upline Spark’s contracting form.

We want to make this process as seamless as possible for you. Please follow the instruction below.

If some questions appear repetitive, it’s because we’ve consolidated questions that are asked across many carriers! It should take no more than 15 minutes to complete.

After completing the form we will follow up to provide you access to our Platform where you can:

Track your contracting status and determine next steps
Update your marketing profile, access the Spark CRM, and continue with the rest of onboarding

We look forward to working together! If you have any questions, please don’t hesitate to reach out to your Strategic Growth Manager or email support@sparkadvisors.com.

Before getting started, are you completing this form for yourself, or on behalf of a downline agent?

Myself

Downline agent

Is this your first time contracting through Simple Choice / Spark? Answer "Yes" if you aren't sure.

Yes

No, I am already contracted and only want to add additional carriers

Agent First Name

(As it appears on your license)

Agent Last Name

Agent Business Email Address

This is the email we will use for all correspondence with you.

Your direct upline

If you don't know, write "Don't know"; if direct, write "Simple Choice"

Agent NPN number

If you don't know your NPN number, you can search for it here: https://nipr.com/help/look-up-your-npn Please enter your first name, last name, and NPN number as it appears on NIPR.

What contract level will you be requesting?

Street Agent -- commissions are assigned to me

Licensed Only Agent -- commissions are assigned to an upline

Agency-level above street agent (e.g. GA, MGA, SGA) -- only select if you have discussed this already with your agency principal or Strategic Growth Manager

Your Personal Information

Do you have preferred? Leave blank if you go by your legal name

Your Social Security Number (enter without hyphens)

Date of Birth

Format: m/d/Y e.g. (4/21/1998)

Your Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Your Mailing Address (leave blank if your home address is the same as your mailing address)

Address Line 1

Address Line 2

City

State

Zip Code

Your mobile number. Enter the phone number you would want us to use to contact you, not the one you use for clients.

If you have a secondary number you would like us to have, enter it here. Otherwise, leave it blank.

What is your resident state?

What is your license number?

Have you already completed the most recent year's AHIP certification?

Yes

When do you expect to complete it?

Business Information

Do you write business through an entity? For example, if you are the full or partial owner of an LLC and write business through it, select "Yes".

Yes

What is your business entity's name?

What is your business entity's tax ID number?

Is your business licensed as an agency? You should have an NPN number for the agency if you answer "Yes".

Yes

If you don't know it, search on NIPR using your FEIN number. https://nipr.com/help/look-up-your-npn

New or Transfer

Is Mutual of Omaha a new contract, or are you currently contracted and transferring it?

New Contracrt

Currently contracted; I want to transfer it

Acknowledgments

Do you grant us permission to contact you by email and/or text messages with Medicare trainings, Carrier updates, and other resources?

Yes

By completing this form, I acknowledge that all information is true and correct to the best of my knowledge (enter your full name).

Simple Choice -- Contracting Form

Medicare Advantage Contract Requests

Your Personal Information

Business Information

State Selection

New or Transfer

Agent Questions... Almost Done!

Acknowledgments