EmailMe Form - USBA ONBOARDING

Agent Name *

First Last

Agency

Agency Principal

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Agent Phone *

### - ### - ####

Agent Email *

Regional Sales Director *

Contracting Options *

No Medicare Contracting

The Referral Depot*

Product Contracting*

*ACH & W-9 form required.

Contracting Contact

Contracting Contact Phone

### - ### - ####

Select Products/Carriers For Contracting*

*Not all products available in all states.
Check with your Regional Sales Director.

Medicare Options

Supplements

MAPD Plans

PDP Plans

Individual Health(Michigan Only)

Priority Health

Priority Medicare

Priority GA Affiliation Change

Short Term Medical

Priority Health(MI Only)

IHC

National General

Individual/Group Indemnity

Manhattan Life Affordable Choice

Select Med

Click here for Manhattan Contracting.

Click Here For Select-Med Contracting

Group Gap Plan

National Guardian Pre Med Defender

Hospital Indemnity

Guarantee Trust Life Advantage Plus

Critical Illness

SureBridge Cancerwise

Mutual Of Omaha

Short Term Recovery / Nursing Home

Guarantee Trust Life

Medico

Dental/Vision/Hearing

Manhattan Life Direct

Life Insurance

Assurity

Travel Insurance

IMG Global/Patriot

Click Here For IMG Global Contracting

Priority GA Change Form(MI Only)

W-9 Form

ACH Form

Check here if currently contracted with one or more the following carriers.

Comments

Select Products/Carriers For Contracting* *Not all products available in all states. Check with your Regional Sales Director.

Select Products/Carriers For Contracting*

*Not all products available in all states.
Check with your Regional Sales Director.