Sole proprietor application

Last name*

First name*

Middle name

DBA name (if applicable)

Social Security number*

Date of birth*

Address*

City*

State*

Zip code*

Agency phone number*

Agency fax number

Email address*

Email address to send monthly commission statements (if different from above)

States/health plans (check all that apply)*

Wisconsin - Dean Health Plan

Wisconsin - Prevea360 (East)

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

IPlanRx (WI)**

**We partner with these Field Marketing Organizations for Medicare sales. Check the one that applies.

Special considerations

Statement of intent*

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 in the near future 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, including Medicare or Medicaid?*

Yes No

Have you ever been barred, or are you aware of actions that could result in debarment, by the General Service Administration from being a government contractor?*

Yes No

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

Yes No

Explain any "Yes" answers above

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

Yes No

Sole proprietor

Sole Proprietor application

Required attachments to upload with application

Application form

Have you attached all the proper documents to this application? Your application will not be processed without all of the proper documentation that is needed with this request.