Sole proprietor application

Sole proprietor form

Thank you for your interest in joining us as a sales partner! Use this form to apply for contracting if you are a licensed agent doing business independently.

If you are seeking a contract for your agency and will have more than one licensed agent, see the new agency (brokerage) form. If you are seeking appointment through the account of an agency or brokerage that has an existing contract, see our agent appointment form.

Our sales leadership team review all applications for new contracts. If approved, your contract will go into effect the month you submitted your application.

Required attachments to be uploaded with application

  • W-9
  • EFT authorization form
  • Check or other bank document
  • Declarations page of current errors & omissions policy
  • State insurance license(s)

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.
Including Medicare or Medicaid
Please provide additional information to help us determine if our partnership will be an effective one, such as: Background of agency, mission statement, geographic location(s), and sales history and expectations
Please use a mouse or your finger to sign your name in the box above.

Have you attached all the proper documents to this application? Your application will not be processed without all of the proper documentation that is needed with this request.