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Medicare Carrier Contracting

Name: Pandora Insurance
Price range: $

Get contracted and appointed to start selling some of the nation’s top health insurance carriers in the Medicare market. Get started selling Medicare plans to your senior clients 65 and older, by completing the simple contracting form below.

First, please select the carriers you are interested in below and then click next:

- Step 1 of 3

Individual ACA Carriers

Aetna Medicare
AvMed Medicare
Cigna Medicare
Florida Blue
Humana
Molina Healthcare
Oscar Health
Simply Healthcare
UnitedHealthcare
Wellcare/Allwell

Name *

First

Middle

Last

Information entered must match agent's license

Email *

Phone *

State License *

NPN *

Date of Birth *

Social Security # *

SS# is required to complete onboarding with carriers. Note: this is a secured site.

Address *

Address Line 1

City

State

Zip Code

1. In the past 3 years, have you ever had a professional license refused, revoked, suspended; or, has disciplinary action been taken against you by a regulatory agency? *

2. Are you currently indebted to any insurance company or agency, or is there any dispute regarding your insurance accounts? *

3. Have you ever pled guilty or no contest or been convicted of any violation of law other than minor traffic violations? *

Signature *

Clear Signature

I hereby represent that the answers and statements (the “information”) I am providing Pandora Insurance on this application are correct, complete, and true, to the best of my knowledge. By submitting this form agent authorizes Pandora Insurance to submit a request for appointment to insurance carriers selected on the agent’s appointment request form, on Agent’s behalf. Agent agrees to complete any documentation reasonably requested by any insurance carrier. I understand that my agency may contact me when I need to answer carrier specific questions.

W9 Form