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First Name
Last Name
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Email
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Password (8 Characters Minimum)
Street Address
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City
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County
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State
Please select a State
Alabama
Arkansas
Arizona
Alaska
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Zip Code
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Is street address and shipping address the same?
Yes
No
Shipping Address
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Shipping City
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Shipping State
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Shipping Zip Code
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Mobile Phone Number
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National Producer Number
Find your National Producer Number
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Do you speak more than 1 language fluently?
Yes
No
Select the languages you speak fluently
English
Cuban
Bengali
Arabic
Haitian Creole
Cantonese
Hmong
Spanish (Spain)
Dominican
Hindi
Russian
French Creole
Mandarin
Japanese
Mexican
Italian
Portuguese
Bosnian
French
Chinese
Puerto Rican
Panjabi
Polish
English Creole
Tagalog
Vietnamese
Other language(s), not listed above
In which states do you hold an active life
AND
health license?
"Please include resident state."
Alabama
Arkansas
Arizona
Alaska
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Are you AHIP Certified?
Yes
No
Which, if any, of the licenses below, do you hold?
Property / Casualty
Series 63
Series 6
Series 7
Type of Work Desired
I will only work remotely from home
I will only work face to face
I will work face to face or in a physical call center
I just want to work
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Company Appointments
5 Star AFBA
AFLAC
Abacus
AlG
Allstate
American Fidelity
American Public
Assurant
Boston Mutual
Chubb
Colonial
Combined
Guardian
Humana
ING
Liberty Mutual
Lincoln Financial
Mass Mutual
Met Life
Monumental Life
Mutual of Omaha
Prudential
Standard
Texas Life
The Hartford
TransAmerica
Trustmark
US Able
United Teacher's
Unum / Provident
Wellfleet
Other Companies not listed above
Do you hold any insurance designations?
Yes
No
Designations Held
AlA
AIS
APA
DARM
CFP
CLCS
FSS
REBC
AlAF
AIT
API
AU
CHFC
CLU
INS
RHU
AIC
AFSB
ARE
CAP
CIC
CPCU
LUTCE
AIM
AMIM
ARC
CAS
CISR
CRM
PLCS
How often have you used the following enrollment platforms & software?
1 to 5 times
5 to 10 times
More than 10 times.
ADP Workforce Now
Aflac Sng
Alight
All State AllApp
BML Enroll
Bconnected
BenSelect
Benefit Contact
Benefit First
Benefit Solver
Benelink
Benelogic
Benetrac
Boston Mutual
Bswift
Ceridian
Colonial Harmony
Common Census
Ease
Employee Navigator
Enroll My Way
Everwell
Falcon Technology
GATHR
HR Intouch
Humana
ING Enroll
Isolved
Motivano
Oracle
Paycom
Paylocity
PeopleSoft
Plan Source
Premier
Resource
Selerix
UKG (Ultipro)
UNUM Plane biz
Uenroll
Ultipro
We Care Enrollment
Workday
Other enrollment software not listed above
Select the word that applies.
Excellent
Very Good
Good
Inexperienced
On face to face enrollments. I am
On call center enrollments. I am
On group presentations. I am
Working on a computer. I am
My knowledge of core benefits is
My knowledge of critical illness coverage is
My knowledge of accident coverage is
My knowledge of LTC coverage is
List all brokers & enrollment firms hiring you in the past. If none, so state.
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Upload a resume, if you wish.
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