Sole proprietor 

female manager on laptop in cafe

Sole proprietor application

Please use the form below 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 meets monthly to review all applications for new contracts. Applications are due by the first of the month, and you will be notified of the decision by the 15th. If approved, your contract will be effective the first of the following month. The contracting period closes each year during the fourth quarter.

Required attachments to upload 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


**We partner with these Field Marketing Organizations for Medicare sales.
Example: languages spoken
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 answer the following questions truthfully and completely. Please include an explanation of any "yes" answers in the text box provided below.
Please include dates, persons and government entities involved, and attach relevant documentation, such as court decrees or findings of investigation.
Required: W-9, signed EFT Authorization form, check or bank document, declarations page of current E&O policy, and state insurance license(s)
Please use a mouse or your finger to sign your name in the box above.