Supplemental Contracting

Name: Pandora Insurance
Price range: $

Get contracted and appointed to start selling some of the nation’s top supplemental insurance plans to your clients. Including Dental, Vision and more. Complete our form below:

First, please select the carrier below and complete the form:

Supplemental Benefit Plans

(Medigap, Short Term, Dental, Vision, Critical, Accident)
(Medigap, Dental, Vision, Hearing, Cancer, Stroke, Accident)
(Short Term, Dental, Vision, Critical, Accident)

Name *

First

Middle

Last

Information entered must match agent's license

Email *

Phone *

NPN (National Producer Number) *

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.

© Pandora Insurance. All Rights Reserved. This page is for agent use only. Distribution to Medicare Beneficiaries is not permitted. Not affiliated with the United States government or the federal Medicare program. Not all products are available in all areas. Exclusions and limitations may apply.

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Supplemental Contracting

First, please select the carrier below and complete the form: