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New Agent

New Agent Contracting Request Form

Basic Info

Please fill out all information completely. If it does not apply, write “NA.”

First Name:

Last Name:

Date of Birth:

Email:

Phone:

Fax:

Referred by: (Please type "NA" if None)

Your Address

Address 1:

Address 2:

City:

State:

Zip Code:

Other Info

Social Security #:

Driver's License #:

TaxPayerID (If applicable)

State License #:

National Producer #(NPN)

Affiliated Agency/Downline:

Carriers you currently sell:

Errors & Omission Insurance:

Click to Attach E&O

Below are list of contracts available for request:

Please Check the completed Certifications:

Most Current AHIP

AML - Anti- Money Laundering

Most Current Federally-dacillated Marketplace (FFM) Training

Medicare Advantage

All Medicare Advantage

Aetna-SilverScript

Allwell

Amerigroup

BCBS

Cigna Health-Spring

Community Health Choice

Devoted

Imperial

Kelsey-Seybold

Molina

Prominence

SCAN

WellCare

United HealthCare

Humana

Memorial Hermann

Christus Health

Medicare Supplement

All Medicare Supplement

Aetna

Amerigroup

BCBS

Capitol Life

Cigna

Federal Life

GPM

Humana

Liberty Bankers

Loyal American

Medico

Mutual of Omaha

United HealthCare

US Fire

Prosperity

Manhattan Life

Life/Final Expense

All Life Product

Aflac

Aetna

American Continental

AIG

American National

Ameritas

Assurity

Banner

Foresters

Gerber

Great Western

John Hancock

Liberty Bankers Life

Loyal American

Minnesota Life (Securian)

Mutual of Omaha

Nacolah

National Farm Life

National Guardian

National Western

Oxford Life

Protective Life

Prudential

Transamerica

United of Omaha

Manhattan Life

Dental & Vision

All Dental

Ameritas

GPM

Mutual of Omaha

Protector

Cigna

NCD Dental

Manhattan Life

Ancillary Products

All Ancillary

AIG

Annexus Athene

Athene National

Annexus Nationwide

National Life Group

National Western

North American

Oxford Life

United Omaha

Manhattan Life

Individual Health-ACA

All ACA

Aetna

BCBS

Cigna

Molina

Ambetter

Oscar

United HealthCare

Community Health Choice

Type Your Full Name:

Thank you for contracting with IMG.

We will get back to you as soon as possible or call the office @ 281-947-6128 if you have any questions.

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We provide guidance and resources to help you grow your insurance agency.

Contact Us

15002 Welcome Ln Houston, TX 77014

support@imgmailbox.com

(281) 947-6128

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8:00 a.m. – 5:00 p.m.

Saturday – Sunday: CLOSED

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