UnitedHealthcare - Medicare Solutions Contracting Application

Legal Name
First:* Middle: Last:*

Alias / Other Names

Home Address

Line 1:*

City: * State:* Country: Zip:*

Home Phone:*
(format 123-456-7890)

Business Phone:
(format 123-456-7890)

Fax:
(format 123-456-7890)

Email:*

Cell Phone:
(format 123-456-7890)

Appointment Type (this must match with the information provided on Agreement and the W-9)*

Individual

Corporation

Mailing Preference (if applying as an individual, but prefer mail to be delivered to your business, fill in the Business Address section below)*

Home

Business

Corporation Name:

Principal:

Business Address (include street, city, state, country, zip):

Line 1:*

City: * State:* Country: Zip:*

Appointed States(must include resident state, must be licensed in each state listed, all states subject to individual review, listing a state does not guarantee appointment for that state):*
Resident State: Non-Resident States: (comma separated)

ERRORS & OMISSIONS COVERAGE*

Note: An active policy declaration page with your name listed as the covered entity must be attached to the fax confirmation page)

Name of Carrier:*

Policy Number:*

Expiration Date:*
(mm/dd/yyyy)

Note: $1,000,000 per occurence and $1,000,000 annual aggregate required.

BACKGROUND INFORMATION

Note: Failure to accurately and honestly answer any of the following questions may result in a declination of your application and appointment with UnitedHealthcare.

1. Have you ever been convicted of a felony?*

Yes

No

2. Have you ever been convicted of a misdemeanor (other than traffic) including an alcohol or drug related offense?*

Yes

No

3. Have you had your driver's license revoked within the past three years?*

Yes

No

4. Have you ever had your insurance or securities license revoked and/or suspended by any department of insurance (even if later reinstated) for any reason?*

Yes

No

5. Have you ever had a complaint reported against you (even if dismissed) by a consumer and/or insurance company for any reason with any department of insurance, NASD, or other regulatory reporting agency including CMS?*

Yes

No

6. Have you ever paid a fine related to a consumer complaint, failure to renew your license or continuing education credit in excess of $500?*

Yes

No

7. Have you ever been excluded, or are you aware of actions that could result in an exclusion, by the Office of Inspector General from participation in a government health care program, including Medicare or Medicaid?*

Yes

No

8. Have you filed for bankruptcy and/or had a bankruptcy discharged within the last five years?*

Yes

No

9. Are you, at the present time, or have ever been within the past five years, invloved in any civil litigation, judgments, liens or foreclosures?*

Yes

No

10. Are you, at the present time, or have you ever been within the past five years, reported as delinquent on state or federal taxes?*

Yes

No

11. Do you owe any insurance company, marketing organization or individual for any premiums collected or monies advanced?*

Yes

No

12. Have you been denied an appointment with any insurance company?*

Yes

No

13. Have you ever been terminated for cause by any insurance carrier?*

Yes

No

14. Have you been denied a bond or application for errors and omissions (E&O) coverage with any company?*

Yes

No

15. Do you have other information related to criminal, insurance related complaints, credit, etc. that was not covered by these questions that you wish to disclose?*

Yes

No

Additional information (include detailed explanations for any "Yes" answers to the aforementioned questions)

CONDITIONS AND AGREEMENTS

I have thoroughly reviewed this application and have knowledgebly answered all questions. By signing below, I hereby attest to all matters set forth above and agree to all matters set forth below. I hereby agree that if any of the companies issue to me any Agreement(s) for which I hereby apply, I will be bound by such Agreement(s). I understand that my supervising officer has specimen forms of the Agreement(s) on file and I have the opportunity to review such Agreement(s). Submitting any application of the company for insurance products, including but not limited to Medicare Advantage and Prescription Drug Plan shall constitute the agreement and all of its terms & conditions and provisions set forth therein. I acknowledge that by signing this Appointment Application and submitting any such insurance application for Insured Product, I agreed to the terms and conditions. Also, in future, no signature is necessary.

DISCLOSURE
I have executed this Appointment Application as evidence of the understanding and acceptance of its consent terms, and I also agree that I will not solicit business until I receive notification from the Company. I have satisfied all of the certification requirements for the products which I intend to sell. I also understand that as a part of an approval process, the Company may obtain an investigative consumer report which will confirm information regarding my character, general reputation, credit history, personal characteristics and mode of living. I hereby authorize the Company to obtain such a report. *

I agree

ELECTRONIC FUND TRANSFER

SecureHorizons will directly deposit the check into your bank account. The deposit is made according to the current Commission Deposit Schedule.

FUND TRANSFER AUTHORIZATION

I hereby authorize the deposit of all due payments to the checking account (indicated below).

I reserve the right to revoke and cancel this authorization. The cancellation of the authorization will take effect upon written notice received by SecureHorizons with reasonable time to act on such notice.*

I agree

I don't agree

ELECTRONIC SIGNATURE AGREEMENT

By checking below I certify that all information contained in this document is accurate and can be considered legally binding. *

I agree

General Agent Full Name:*

General Agent Title:

Social Security Number:*
(Numbers only - e.g. 123456789)

Date of Birth:*
(mm/dd/yyyy)

Your signature:*

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