Sole Proprietor application

Email Address*

Email address to send monthly commission statements (if different from above)

State/Health plans (check all that apply)*

Illinois - WellFirst Health — Provided by SSM Health Plan

Missouri - WellFirst Health

National Producer Number (NPN)*

Do you have certifications from CMS for the current plan year?

FFM

AHIP (Medicare)

Primary business market (check all that apply)*

Individual

Medicare - Plan Advisors (MO, IL)*

*We partner with Plan Advisors a Field Marketing Organization for Medicare sales.

Special considerations

Have you previously had or applied for a contract with any of our health plans?*

Yes No

If yes, please explain

Please answer the following questions truthfully and completely. Please include an explanation of any "yes" answers in the text box provided below.

1. Have you ever pled guilty or “nolo contendere” to or been found guilty of a felony?*

Yes No

2. Have you ever been refused a surety or fidelity bond?*

Yes No

3. In the last seven (7) years, have you been the subject of a business-related bankruptcy petition or proceeding?*

Yes No

4. Have you ever had, or do you in the near future anticipate, any disciplinary action from any insurance Regulatory Authority?*

Yes No

5. Have you ever had a contract and/or appointment with another insurance company terminated for reasons other than non-production?*

Yes No

6. Has your insurance license ever been suspended or revoked?*

Yes No

7. Have you ever had a complaint filed against you with an insurance Regulatory Authority?*

Yes No

8. Have you ever been excluded, or are you aware of actions that could result in exclusion, by the OIG from participation in a government health care program?*

Yes No

Including Medicare or Medicaid

9. Have you ever been barred, or are you aware of actions that could result in debarment, by the General Service Administration from being a government contractor?*

Yes No

10. Have you ever applied for or received an appointment/listing with SSM Health Entities before?*

Yes No

Explain any "Yes" answers above

I have documents to attach in support of my answers to questions 1- 10 above*

Yes No

Statement of intent*

Please provide additional information to help us determine if our partnership will be an effective one, such as: Background of agency, mission statement, geographic location(s), and sales history and expectations

Sole proprietor application

Sole proprietor form

Required attachments to be uploaded with application

Application form

Have you attached all the proper documents to this application? Your application will not be processed without all of the proper documentation that is needed with this request.