UnitedHealthcare Successor Agent Program
Interest Form
Thank you for your interest in UnitedHealthcare’s Successor Agent Program. Fill out the following information completely and
legibly to enable UnitedHealthcare to review eligibility of the Original and Successor Agents.
By signing this form, Original Agent/Agency and Successor Agent/Agency are indicating that they have read the Successor Agent
Program Requirements and that they have an interest to transfer Original Agent’s/Agency’s UnitedHealthcare book of business
to Successor Agent/Agency. UnitedHealthcare will notify the Original Agent/Agency regarding eligibility within approximately
30 days of receiving this signed form. If eligible, a formal contract between Original and Successor Agents/Agencies will follow.
Transfer of the book of business will be effective immediately upon completion of this process.
General Eligibility Criteria:
1. Original and Successor Agents must not be the subject of an open complaint investigation
2. Overrides are not eligible for transfer to a lower level (for example, General Agent to Agent)
Please refer to the Agent Guide for the complete Successor Agent Program policy.
ORIGINAL AGENT/AGENCY INFORMATION
NAME:_____________________________________
PARTY ID #:_________________________________
EMAIL:____________________________________
SIGNATURE AGENT or AGENCY PRINCIPAL:
___________________________________________
SIGNATURE DATE:____________________________
Will down-line be moving to new Agent or Agency?
(Circle One) Y N N/A
All standard release rules in the Agent Guide apply.
If the Original Agent and/or the Original Agent’s
downline move to the Successor Agent’s hierarchy,
approval from the Original Agent’s current FMO is
required and must be submitted with this Successor
Agent Interest Form.
SUCCESSOR AGENT/AGENCY INFORMATION
NAME:____________________________________
PARTY ID #:________________________________
EMAIL:___________________________________
SIGNATURE AGENT or AGENCY PRINCIPAL:
_________________________________________
SIGNATURE DATE:__________________________
Please describe the plan for servicing the members
in the book of business being transferred.
___________________________________________
___________________________________________
__________________________________________
___________________________________________
___________________________________________
Attestation Language for Interest Form Completed by Agent Seeking to Transfer their Business to another Agent:
I attest that:
I am not seeking to transfer my business for any fraudulent or inappropriate purpose including, but not limited to,
for the purpose of avoiding creditors, restitution or garnishment.
The
re are no pending complaints or open inquiries with any government authority, including, but not limited to a
department of insurance, regarding myself or any company of which I am a shareholder* and/or officer.
There are no pending criminal charges against me or any company of which I am a shareholder* and/or officer.
Neither I nor any company of which I am a shareholder* and/or officer has been convicted of a crime in the last two
years.
If I cannot attest to the above, I give the following explanation for consideration by United:
Return form to:
sh_commissions_administration@uhc.com
Questions: Call the Producer Help Desk (PHD) Successor Agent Hotline at 888-240-9165 UnitedHealthcare reserves the right to rescind
the Successor Agent Program at any time. Any rescission of the program will not impact books of business already transferred, but
could impact pending requests.
*Excludes publicly traded companies
Successor Agent Interest Form
v1.5 04/2021
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