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Soares & Associates

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Soares & Associates

Home
About Us
Contract
Contact Us

Contract

Carrier Contracting

For independent agents or agencies.

Carrier Contract – Please complete form for contracting. **May take 24 to 48 hours.

Date Request Sent*

Is this an Agency Contract Y/N?*

If Yes, Put Agency Name – If Not Put “No”*

If Yes Agency Tax ID Id – If Not Put “No”*

First Name * Must Match NIPR*

Last Name * Must Match NIPR*

Email*

Phone*

Street Address*

City*

State*

Zip*

Date of Birth*

NPN National Producer Number*

SSN*

State License Number Else Use NIPR Number*

Resident State*

Carrier Name ( You may request contracts for multiple carriers. Example: UHC, Humana, Silac, Sagicor) *

Are you New to Carrier or Transfer? New/Transfer*

Message (Please Give Details If Choosing Multiple Carriers)

You agree to receive email communication from us by submitting this form and understand that your contact information will be stored with us.

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