First Name *

Middle Name

Last Name *

Date of Birth * ex. MM-DD-YYYY

SSN * ex. XXX-XX-XXXX

Company or DBA

Tax ID or EIN ex. XX-XXXXXXX

Email *

Confirm Email *

Password

Cannot contain your first or last name.
Must be at least 8 characters in length.
Must contain a number, special character, upper case letter, and lower case letter.

Password *

Confirm Password *

Cell Phone * ex. XXX-XXX-XXXX

Alt Phone ex. XXX-XXX-XXXX

Physical

Address 1 *

Address 2

State *

City *

Zip *

Same as Physical

Mailing

Address1 *

Address2 *

State *

City *

Zip *

Active, non-resident-licensed states (hold shift for multiple) *

Producer Info

National Producer Number: *

Resident State*

Resident State License Number*

Are you AHIP certified for the current year (yes/no)*

Background Information

Yes No

State: *

Resident: *

License Number: *

Texas Temporary License? Yes No

If yes, please explain:

Criminal History Questionnaire

Click here to download and review document.

Please review the above document before answering the following questions.

Applicant Name *

Yes No

If you answered Yes, provide city, county, and state of conviction and date and nature of the offense, along with sentencing information. Enter N/A if you answered "No" and this question does not apply to you. *

Signature *

Work History

Input your work history since 2018

Company name

Start date

End date

Position

City

Work Histories

Company Name	Start Date	End Date	Position	City

Background

Yes No

Click here to download and review document.

I agree

Please check 'I agree' at the bottom of each disclosure after reviewing.

Signature *

Assessment

Signature *

ACH Deposit Information

Account Name: *

Account Type: *

Account Number: *

Routing Number: *

W-9 Information

Click here to download and review document.

1 Name (as shown on your income tax return)

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:

Individual/sole proprietor or single-member LLC

C Corporation

S Corporation

Partnership

Trust/estate

Limited Liability company. Enter the tax classification (C=C Corporation, S=S Corporation, P=Partnership)

Other (see instructions)

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting code (if any)

5 Address (number, street, and apt. or suite no.)

6 City, state, and ZIP code

7 List account number(s) here (optional)

Payment Details

Choose registration package:

Wholesale Agent Registration: Includes 10 PERA appointments and contracting

Wholesale Contracting Only: Includes wholesale carrier contracting fees and library of presentation materials for K-12 appointments

(Nonrefundable)

This Page Is Secure.

Currently accepting the following cards:

Here are some of the ways protects your information:

Our website uses 256-bit Secure Socket Layer (SSL) encryption to transmit your information.
Your financial information is never divulged to anyone.
All transactions are processed by a Payment Card Industry (PCI) Level 1 compliant processor.
We do not store your credit card information.

Enter your credit card information: *

Card Type Card Number Expiration Date (mm/yy) Cardholder's Name Card Validation Code

Billing Zip

Congratulations!

Welcome to the team! Your registration is now being processed.

As part of the Exact Medicare System your registration fee has been waived for the first 45 days. If you submit two pieces of business through the back office during this time you will not have to pay a registration fee. If you do not submit two pieces of business through the back office within your first 45 days, you will be required to pay the registration fee of $225 to continue to have access to your Exact Medicare back office.

Your Agent ID is .