LICENSED-ONLY AGENT (LOA) CONTRACTING SUBMISSION FORM

Please fill in all of the required information below. This form will automatically populate into a PDF for the Fidelis Information Form.
You can attach all relevant documents by clicking the “Choose Files” button at the bottom of the page, including any additional pieces discussed with Contracting.

If you have any questions or need assistance, please contact the Contracting Department at contracting@fidelisins.com or call 480.877.4948

Agent Name:

Immediate Upline:

SSN:

Tax ID:

Address:

Unit:

City:

State:

Zip:

Business Address:

Unit:

City:

State:

Zip:

Business Phone:

Cell Phone:

Email Address:

Date of Birth:

Agent NPN:

Required Documents:

AHIP
E & O
License

Attachments

Clicking “Submit” will open a screen with a form which will add the information you provided above.

Please carefully review that information and fill out the remaining fields, including your signature.

Once you click “I agree,” the documents you’ve uploaded and the signed forms will be sent to our Contracting Team.