Agent Appointment form

Application to add new agents to your brokerage account

Please use the application below to add new agents to your agency or brokerage account. If you do not yet have an account, please see the New Agency (Brokerage) form. If you are a sole proprietor or independent agent, please see the Sole Proprietor form.

The processing time for agent applications can take up to two weeks. You will receive a welcome email notifying you when your appointment is complete.

State insurance license(s) are required to be uploaded as an attachment with this application

Have questions or need help? Email us at or call us toll-free at 877-317-3046.

Application form

 *Required field

*We partner with Plan Advisors a Field Marketing Organization for Medicare sales
Please answer the following questions truthfully and completely. Please include an explanation of any "yes" answers in the text box provided below.
Please include dates, persons and  government entities involved, and attach relevant documentation, such as court decrees or findings of investigation.
Required: Copy of insurance license from each state in which you are seeking an appointment
Please use a mouse or your finger to sign your name in the box above.