Existing Agency Info Sheet revised 07-12 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Contracted Agency Information' section. Enter your business name, address, city, state, zip code, phone number, fax number, website address, and tax ID number.
3. Next, move to the 'New Agent Information' section. Provide the first, middle, and last name of the new agent along with their email address and home address details including city, county, state, zip code.
4. Continue by entering the home phone and cell phone numbers. Include the date of birth and city of birth for the new agent.
5. Fill in the social security number and resident state. Enter both resident and non-resident agent license numbers as well as FFM User ID and National Producer Number.
6. Indicate any special considerations such as languages spoken and check if a MAPD Sales Certification is requested.
7. Address any legal questions listed in the form. If applicable, provide detailed explanations on a separate page.
8. Complete the current E&O insurance carrier information including policy number.
9. Finally, review all entries for accuracy before signing and dating the form at the bottom.

Start using our platform today to streamline your document completion process for free!