Agent appointment application

Contracted agency name*

Business location*

Agent first name*

Agent middle name*

Agent last name*

Social Security number*

Date of birth*

Personal address*

City*

State*

U.S. Zip code*

Agency phone number*

Agency fax number

Email address*

Do you have a current insurance producer license in the states you selected?*

Yes No

National Producer number (NPN)*

Do you have certifications from CMS for the current plan year

FFM

AHIP (Medicare)

Primary business market (check all that apply)*

Large group

Small group

Self-funded/Level-funded

Includes ASO (self-funded or level-funded)

Individual

Medicare

Have you previously had or applied for a contract with any of our health plans?*

Yes No

If yes, please explain

Please answer the following questions truthfully and completely. Please include an explanation of any "yes" answers in the text box provided below.

Have you ever pled guilty or “nolo contendere” to or been found guilty of a felony?*

Yes No

Have you ever been refused a surety or fidelity bond?*

Yes No

In the last seven (7) years, have you been the subject of a business-related bankruptcy petition or proceeding?*

Yes No

Have you ever had, or do you anticipate, any disciplinary action from any insurance Regulatory Authority?*

Yes No

Have you ever had a contract and/or appointment with another insurance company terminated for reasons other than non-production?*

Yes No

Has your insurance license ever been suspended or revoked?*

Yes No

Have you ever had a complaint filed against you with an insurance Regulatory Authority?*

Yes No

Have you ever been excluded, or are you aware of actions that could result in exclusion, by the OIG from participation in a government health care program?*

Yes No

Have you ever applied for or received an appointment/listing with SSM Health Entities before?*

Yes No

Explain the details of any "Yes" answers above

Please include dates, persons and government entities involved, and attach relevant documentation, such as court decrees or findings of investigation.

I have documents to attach in support of my answers to questions 1- 10 above*

Yes No

Agent appointments