Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 4Seasonal Licensed Insurance Agent Application Apply for the upcoming OEP season. Please have your NPN, state license information, and licensing documents ready.Applicant InformationName *FirstMiddleLastAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of BirthSocial Security NumberEmail *Phone *Upload USA ID Capture With Your Camera Camera Preview Copy of Social Security Card Capture With Your Camera Camera Preview NextLicensing InformationLicense TypeHealth & Life Insurance LicenseHealth Insurance LicenseLife Insurance LicenseHealth & Life Insurance LicenseAre you also applying on behalf of a business entity?YesNoNational Producer Number (NPN) *Business Entity NPN * Which States are you licensed in, add the states StateAlabama ALAlaska AKArizona AZArkansas ARCalifornia CAColorado COConnecticut CTDelaware DEFlorida FLGeorgia GAHawaii HIIdaho IDIllinois ILIndiana INIowa IAKansas KSKentucky KYLouisiana LAMaine MEMaryland MDMassachusetts MAMichigan MIMinnesota MNMississippi MSMissouri MOMontana MTNebraska NENevada NVNew Hampshire NHNew Jersey NJNew Mexico NMNew York NYNorth Carolina NCNorth Dakota NDOhio OHOklahoma OKOregon ORPennsylvania PARhode Island RISouth Carolina SCSouth Dakota SDTennessee TNTexas TXUtah UTVermont VTVirginia VAWashington WAWest Virginia WVWisconsin WIWyoming WY Add Another State License Remove License Carrier AppointmentsTell us about any active carrier appointments you currently hold.Are you currently appointed with any insurance carriers?YesNo Current Carrier Appointments Carrier Name *--- Select Choice ---Florida BlueNational LifeAetnaOther / Not ListedIf Others, Enter Carrier NamesSeparate multiple carriers with commas.State(s) of Appointment *Separate multiple states with commas. Add Another Carrier Remove Carrier Years of Insurance Sales Experience *--- Select Choice ---Less than 1 Year1-2 Years3-5 Years6-10 Years10+ YearsAre you available for the full OEP assignment from October 1, 2026 through February 1, 2027, including one required week of training? *Yes, I am availableNo, I am not availableBackContinue to DocumentsDocuments and FFMUpload Proof of Insurance License * Drag & Drop Files, Choose Files to Upload, or Capture With Your Camera Camera Preview Upload one combined PDF or separate images of proof of insurance license.Do you currently have an active FFM certification for the upcoming plan year?YesNoUpload Current FFM Certification * Drag & Drop Files, Choose Files to Upload, or Capture With Your Camera Camera Preview BackContinue to CertificationApplicant Certification Please review and confirm each statement before submitting your application. I 2027, to I certify that all information provided in this application is true and accurate. *yesI authorize Every Health Group to verify my insurance licensing information. *YesI understand that engagement or employment is contingent upon successful license verification and any required pre-employment screening. *YesBackSubmit Application
