Skip to content
Call Us: 402.330.8700
Home
Who we are
What We Do
Individual Health
Group Benefits
Split Cases/Client Referral
Medicare
Life, Disability, LTC, Annuities
Resources
OCI Experience Summit
Videos/Webinars
Circle of Excellence Incentive Program
Agent Bonus Programs
Compensation Disclosure
Our Staff
Our Staff
Join Our Team
Partner With Us
Login
Search for:
Carrier Appointment Request
Home
Carrier Appointment Request
Carrier Appointment Request
Request Type
New Appointment Request
Adding State to Current Appointment
Agent Name
(Required)
First
Last
Agency Name (if applicable)
Segments
(Required)
Group
Individual
Medicare
Solutions
Group Name (if applicable)
Effective Date (if applicable)
MM slash DD slash YYYY
States
(Required)
IA
KS
MO
MN
ND
NE
OK
SD
IA Group Carriers
Aetna
Allstate
Delta Dental
LFG
Medica
Metlife
Principal
UHC
UNUM
IA Individual Carriers
Allstate
Medica
Oscar
Pivot Health
UHC ACA
UHOne
IA Medicare Carriers
Aetna MA/PDP
Aetna Med Supp
Allstate
Cigna PDP
Cigna Med Supp
Humana
Medica
Mutual of Omaha Med Supp
UHC Medicare Solutions
Wellcare
KS Group Carriers
Aetna
Allstate
LFG
Metlife
Principal
UHC
UNUM
KS Individual Carriers
Allstate
Ambetter
Medica
Oscar
Pivot Health
UHOne
KS Medicare Carriers
Aetna MA/PDP
Aetna Med Supp
Allstate
BCBS of Kansas
Cigna PDP
Cigna MA
Cigna Med Supp
Medica
Mutual of Omaha Med Supp
UHC Medicare Solutions
Wellcare
MN Group Carriers
Allstate
BCBS of Minnesota
Delta Dental
LFG
Medica
Metlife
Principal
UHC
UNUM
MN Individual Carriers
Allstate
Medica
MN Medicare Carriers
Aetna MA/PDP
Aetna Med Supp
Allstate
Cigna PDP
Cigna Med Supp
Medica
Mutual of Omaha Med Supp
UHC Medicare Solutions
Wellcare
MO Group Carriers
Allstate
LFG
Medica
Metlife
Principal
UHC
UNUM
MO Individual Carriers
Allstate
Ambetter
Anthem BCBS
Medica
Oscar
Pivot Health
UHOne
MO Medicare Carriers
Aetna MA/PDP
Aetna Med Supp
Allstate
Anthem BCBS
Cigna PDP
Cigna MA
Cigna Med Supp
Medica
Mutual of Omaha Med Supp
UHC Medicare Solutions
Wellcare
ND Group Carriers
Allstate
Delta Dental
LFG
Medica
Metlife
Principal
UHC
UNUM
ND Individual Carriers
Allstate
Medica
Pivot Health
UHOne
ND Medicare Carriers
Aetna MA/PDP
Aetna Med Supp
Allstate
Cigna PDP
Cigna Med Supp
Medica
Mutual of Omaha Med Supp
UHC Medicare Solutions
Wellcare
NE Group Carriers
Aetna
Allstate
BCBSNE
Delta Dental
LFG
Medica
Metlife
Principal
UHC
UNUM
NE Individual Carriers
Allstate
Ambetter
BCBSNE
Medica
Oscar
Pivot Health
UHC ACA
UHOne
NE Medicare Carriers
Aetna MA/PDP
Aetna Med Supp
Allstate
BCBSNE Med Supp
BCBSNE MA/PDP
Cigna PDP
Cigna Med Supp
Humana
Medica
Mutual of Omaha Med Supp
UHC Medicare Solutions
Wellcare
OK Group Carriers
Allstate
LFG
Metlife
Principal
UNUM
OK Individual Carriers
Allstate
Ambetter
BCBS of Oklahoma
Medica
Pivot Health
UHC ACA
UHOne
OK Medicare Carriers
Aetna MA/PDP
Aetna Med Supp
Allstate
Cigna PDP
Cigna MA
Cigna Med Supp
Medica
Mutual of Omaha Med Supp
UHC Medicare Solutions
Wellcare
SD Group Carriers
Allstate
LFG
Medica
Metlife
Principal
UHC
UNUM
SD Individual Carriers
Allstate
SD Medicare Carriers
Aetna MA/PDP
Aetna Med Supp
Allstate
Cigna PDP
Cigna Med Supp
Medica
Mutual of Omaha Med Supp
UHC Medicare Solutions
Wellcare
Is the agent already in AGB?
(Required)
Yes
No
Agent Email Address:
Is this a pre-appointment request?
(Required)
Yes
No
Client Name:
Carrier:
(Required)
Date application was signed:
MM slash DD slash YYYY
State request:
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Type of insurance:
Life
LTC
Annuity
Final Expense
Accidental Death
Disability
LTC Rider:
Yes
No
Submitted by:
(Required)
Aaron Clark
Darwin Couch
Eric Larson
Hannah Ries
Jessica Colo
John Smith
Nate Berger
Nick Elbert
Randy Somercik
Other
Requester Name
(Required)
Additional Info:
Page load link