AGENT CONTRACTING

Request a contract for your agent or agency.

First, tell us who YOU are. Then enter the agent or agency you want contracted and their commission amounts.

← Change request type

YOUR information

You are the person submitting this request. Enter your own contact information here.

YOUR full name *

YOUR agency name *

YOUR email address *

Who needs the contract?

Enter the agent or agency you want contracted. For an agency, use its legal business name and the email and phone number of the person handling its contracting.

Agent or agency name to contract *

Their email address *

Their phone number *

Once approved, the DocuSign link will be sent to the email address in section 2. Double-check that it belongs to the agent or agency you want contracted.

THEIR commission amounts

Enter the commission the agent or agency in section 2 should receive for each plan. PEPM means dollars per employee per month. Example: enter 10 for $10 per employee per month.

Their Premier PPO commission *

PEPM

Their MVP PPO commission *

PEPM

Not sure what amounts to enter? Contact the AffordaCare team before submitting.

Before submitting: section 1 is YOUR information. Sections 2 and 3 are for the agent or agency receiving the contract. Submitting a request does not confirm approval.