Onboarding Request form

Save & Return

Use an account to return to saved work.

Type of Agent Appointment, check all that apply *

if assigning commissions to another agent or agency please list below.

Are you an existing or new agent? *

If you report to another direct upline other than Copeland, please list name of upline and for which carrier below?

Please select the Copeland Sales Marketer/Manager/Managers you work with. *

If applying as a corporation will the principal be a selling agent

Yes

No

N/A

Individual NPN#

Individual Resident License #

Look up NPN

First Name and Last Name as it appears on the resident state Insurance License

Corporation name exactly as it appears on resident state insurance License if applying as an agency

Corporation NPN#

Corporation resident license #

Look up NPN

Gender Identity

DOB(MM/DD/YYYY +

Social Security(no dashes) *

Tax ID if this agent is applying as corporation

Preferred mailing address

Address Line 2

City

State

Zip/Postal Code

County

Email *

confirm email *

Alternate Email

Cell Number *

Alternate Phone Number

Resident State

If you hold a non-resident license and would like to be appointed in that state please check all that apply. Not all states may be available depending on product and uplines appointments. 🛈

MA Plan Comparison Link

Marketplace Plan Lookup

Medicare Supplement Look up

Please select carriers for which onboarding is requested for resident state, if you would like other state appointments please list specifically in note section below. * 🛈

Notes

Bank information-recommended to complete as all ACA carriers are paid by Copeland and this would be required.

Direct Deposit Authorization

Name of financial institution

Routing number

Account number

Account type

Savings

Checking

Authorization

I authorize [company] to initiate credit entries to the account indicated above for the purpose of expense and/or payroll. I also authorize [company] to initiate, if necessary, debit entries and adjustments for any credit entries made in error.

Signature

clear

Voided Check

Attach E&O

Attach copy of license

Attach copy of AHIP

Attach copy of Marketplace certificate

Attach Release

Background Supporting documents