Individual Broker Agreement IAG COM Corporate Agency Agreement CAG COM Provisional Broker Agreement IAG PRVPreferred Agency Agreement • April 3rd, 2017 • Minnesota
AGENT FULL NAME(Last, First, Middle) DATE OF BIRTH/ / SOCIAL SECURITY NUMBER - - # MALE # FEMALE HEALTH INSURANCE LICENSE NUMBER MN WI ND SD Please attach copy of applicable license(s) (REQUIRED) NPN: AGENCY NAME FEDERAL TAX I.D. NUMBER AGENCY ADDRESS CITY/STATE /ZIP CODE AGENCY TELEPHONE FAX NUMBER COUNTY AGENT HOME ADDRESS CITY/STATE /ZIP CODE HOME TELEPHONE FAX NUMBER E-MAIL ADDRESS (Unique & REQUIRED) Send mail to (check one only): □.Agency address □.Home address □ Other - Please provide to Medica 1. Have you ever been convicted of a felony under state or federal law, or a crime involving dishonesty or breach of trust? □.Yes □.No2. Has any insurance disciplinary action ever been taken against you? □.Yes □.NoIf yes to either question, please provide dates, explain, and attach documentation: Errors & Omissions Insurance Carrier(REQUIRED) Level (amount) Exp. date Please attach copy of declaration page Policy Number Held by: # Self # Agency Assign commissions to: #. Agent #
PREFERRED AGENCY AGREEMENT BETWEENPreferred Agency Agreement • July 23rd, 2015
THIS PREFERRED AGENCY AGREEMEN T ("Agreement") is e ffective as of , 2015 (the "Effective Date") between [Agency Name], ("Agency"), and Medica Health Plans, Medica Health Plans of Wisconsin and Medic a Insurance Company (collectively referred to as “Medica”) for the solicitation of Medicare and individual and fam ily business as set forth in this Agreem ent in the states in which such Medica products are sold, in cluding without limitation, the states of Minnesota, Wisconsin, North Dakota, and South Dakota.
