ACA Contract Request

Name (as it appears on license) *

Address

Address *

City *

State *

Country

Postal code *

Thank you for your interest in contracting with Monarch Agency Solutions. Complete the information in the form below to be added to the contracting queue for ACA.

Questions? Call us at 561-720-4532

NOTE: This form is NOT a contract.

This form will indicate your interest in appointing through Monarch Agency Solutions, and then additional contracting links/paperwork and certifications (if applicable) will be required before you begin marketing/selling any carrier products listed on this form. After completing this form, our team will reach out to you with additional instructions for new appointments and transfers.

E-mail Address** Please do not use an email that Medicare or other Health carriers communicate with** It is recommended to create one [email protected] *

Confirm E-Mail *

National Producer Number (NPN) *

Resident State *

Are you requesting to appoint as an individual or an agency? If Agency, your agency MUST be licensed in the state of residency. If you only have a personal license, choose "individual" *

Individual

Agency (Only choose if you have an active LICENSED agency)

Both Individual & Agency

Have you completed your FFM certification? *

Yes

No

FFM User Name *

Note: All agents marketing ACA health plans are required to take the CMS (FFM) Certification. Most ACA carriers require agents to have this certification completed prior to contracting. Questions? Call our Agent Care Team at 561.720.4532.

Who is your ACA Broker Manager/Agency? (Who referred you to us) *

How many health related sales have you made in the last 12 months? (Medicare, ACA, Vision, Dental) *

In order to process this request, we need a copy of your FFM certificate/State Exchange as well as of your state licenses. Send to: [email protected] Please open a new tab and send us the email now.

*

I confirm that I have sent my FFM Certificate/State Exchange and my State Licenses to [email protected]

*

I confirm I understand this form is NOT a contract and I must complete contracting paperwork and be appointed before I start selling/marketing any carrier products

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By clicking "Submit" I understand that this form is not a contract and does not appoint or certify me to sell/market any carrier products. This is a contract request form to indicate my interest in appointing through Monarch Agency Solutions, and I am requesting contracting information for the carriers selected on this form. I understand that I will be receiving contracting links and emails for each carrier selected on this form, and I will not be ready to sell/market with these carriers until I complete each carrier's contract, complete any applicable certifications and the carrier has approved my appointment.

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By clicking Submit I provide my electronic signature expressly consenting to recurring contact from Monarch Agency Solutions regarding Monarch Agency Solutions contracts and training at the phone numbers end email address I provided. Messages may come to me via live, automated or prerecorded telephone call, text message, or email. I understand that my telephone company may impose charges on me for these contacts, and I am not required to enter into this agreement as a condition of purchasing property, goods, or services. I understand that I can revoke this consent at any time.

Signature *

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ACA Contract Request