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Complete Your New Agent Survey

Fill out the brief form below and we will be in touch.

Welcome to MHC!

Please complete the information in this form in it's entirety. Any questions please contact your agency contact to resolve or report issues to us.

Type of Contracting Request

Type of Request

Contract in the Name of

Agent Personal Information

First Name *

Last Name *

Phone *

Email *

Agent Date of Birth *

Agent Gender *

Social Security Number *

Have you ever been convicted of insurance fraud or a felony involving dishonesty or breach of trust? *

Please Provide Your Agent Home Address

Address

Street Address *

City

State

Country

Postal code

Are You Already Licensed?

Are you currently licensed in insurance or seeking to get licensed in insurance? *

Current Agent Licensing Information

What is your agent license number (NPN)?

What year did you first become licensed in insurance?

What types of insurance are you currently licensed in?

Please list initials of states licensed in or if nationally, list "all"

Additional Information

Agency Name

If you have an agency location address other than your home address, please provide it here.

Are you currently contracted under any other aggregate or carrier directly?

If licensed under carriers already, please name the carriers you are contracted under.

Additional Business Information

Business Mobile Number

Business Office Number

Business Fax Number

Agent Additional Preference Information

Are you seeking remote, in-office, or in-field opportunities?

What is your preferred method of contact for us to reach you?

Please list any special interests, certifications, accomplishments, or details that you believe will help influence us in understanding how best we can support you in your career growth.

Where did you hear about us?

Legal Compliance Information

Please Upload Your Agent E&O Policy or Resume Information

Agent Contracting Signature Collection *

Clear

I agree to terms & conditions provided by the MHC. By providing my phone number, I agree to receive text messages from the business.

PLEASE NOTE: After submitting, you will be taken to the Agent Sync portal. Click "Not a member? Click here to register" and create an account unless already a member, in which you can just login and complete registration.

National Producer Number for MHC: 19169797

National Producer Number for Jeremy Patterson: 8827726

Jeremy Patterson and Medicare Health Connections is NOT AFFILIATED with any Government Agency.

We do not offer every plan available in your area. Currently we represent 10 organizations which offer 28 products in your area. Please contact Medicare.gov or 1-800-Medicare or your local state health insurance program, (SHIP) to get more information on your options.

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