Simple Choice Contracting Form

We're excited to have you join Simple Choice!

Please complete this onboarding form so that we can submit documents on your behalf and make the contracting process seamless. If some questions appear repetitive, it's because we've consolidated questions that are asked across many carriers! It should take no more than 10 minutes to complete if you have the information below on hand.

An Agent Success associate will be in touch shortly after completion.

If you plan to contract with a Medicare Supplement company, please have your NPN number, a copy of your E&O insurance, and a copy of a voided check ready.

First Name

Last Name

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

Agent NPN number

Don't know your NPN number? Look it up here: https://nipr.com/help/look-up-your-npn

Are you contracting as an agent or agency?

Agent

Agency

Select agency if you have downline agents.

Agent Social Security Number (enter without hyphens)

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Do you have a business address?

Yes

What is your favorite mailing address?

Business Address

Home Address

Phone Number

Is this a landline or cell number?

Landline

Cell

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

Yes

Contract Requests

Select the carriers that you would like to be contracted with (please discuss with your upline or Strategic Growth Manager if you aren't sure).

Please be advised that some carriers charge resident and-or non-resident appointment fees, as indicated below. If you are requesting one of those carriers (e.g. UHC, Anthem), note which states you'd like to be appointed with in the "additional information" section below.

What is your resident license state?

What is your license number?

Do you have Medicare Advantage / PDP carrier contracts you want to add or transfer?

Yes

Do you have Medicare Supplement / Life carrier contracts you want to add or transfer?

Yes

Your level (default should be street agent)

In which states would you like to contract?

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

Are you currently under another agency for any contract(s) you're requesting?

Yes

Do you have licenses in any of these other products? (any state)?

No, I do not have any other licenses

Life

P&C

Annuities

Other

Do you already have your AHIP certification?

Yes

Do you already have E&O certification?

Yes

If not, you can purchase discounted E&O at this link: https://opsfarm.calsurance.com/cona/start.aspx?pr=16112912&loc_id=PSM103

Please share any additional information here that's relevant to your contracts:

If someone referred, please list their name below (otherwise skip!)

Lastly, to show our excitement about you joining the SCIB team, please enjoy a small gift from us. Enter your shirt size & type, and you can expect a box to arrive at your home address in the next 2 weeks!

Size

Type

Men

Women