Preferred Name *

First Name

Last Name

Legal Name *

as shown on your income tax return

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Residential Phone Number

(###)

###

####

Type of Request *

New Agent (New to UnitedHealthcare)

Hierarchy Change (Agency Change)

Appointment Type *

Please make a selection

Individual

Corporation

Mailing Preference *

Please select one

Residential

Business

Residential Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Address

If different from residential, Must provide if applying as a corporation.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Phone Number *

Best number to contact you.

(###)

###

####

Fax Number

(###)

###

####

*

Have you ever been convicted of a felony?

No

Yes

*

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

No

Yes

*

Have you had your driver’s license revoked within the past three years?

No

Yes

Department of Insurance and CMS *

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?

No

Yes

*

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, FINRA, or other regulatory reporting agency including CMS?

No

Yes

*

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

No

Yes

*

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 and Medicaid?

No

Yes

Credit History *

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

No

Yes

*

Are you, at the present time, or have you been within the past five years, involved in any civil litigation, judgements, liens or foreclosures?

No

Yes

*

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

No

Yes

Other Companies *

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

No

Yes

*

Have you ever been denied an appointment with any insurance company?

No

Yes

*

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

No

Yes

*

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

No

Yes

Other *

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?

No

Yes