Fillable Medicare Plans Contracting Request (Dickerson Insurance Services)

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Medicare Plans Contracting Request (Dickerson Insurance Services)

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Medicare Plans Contracting Request
Agent Name:______________________ Phone: _______________________
Address: _________________________________________________________
E-mail: ___________________________ License #: ____________________
Carrier Contract Requested and Level
• Aetna Agent___ GA___ Currently Contract?___
• Anthem Agent___ GA___ Currently Contract?___
• Blue Shield of CA Agent___ GA___ Currently Contract?___
• Care 1st Agent___ GA___ Currently Contract?___
• Humana Agent___ GA___ Currently Contract?___
• SCAN Agent___ GA___ Currently Contract?___
• Silver Scripts Agent___ GA___ Currently Contract?___
• United Healthcare Agent___ GA___ Currently Contract?___
Current Upline
Agency:_____________________________________________________
Current Downline Agents (if GA): _________________________________
Notes: ______________________________________________________
____________________________________________________________
____________________________________________________________
Please forward this completed form by clicking on the e-mail
link below and attaching the form to the e-mail:
medicare@dickerson-group.com
For more Information N. CA call: (877) 361-7342
For more Information S. CA call: (800) 457-6116
License #0M29112
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Medicare Plans Contracting Request (Dickerson Insurance Services)

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Completed 1 June 2021

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