Humana MGA Assignment Form

Humana MGA Assigment Form

AGENT TO GENERAL AGENCY ASSIGNMENT FORM

General Agency Information

GA NAME: Senior Market Advisors

GA NUMBER: 1567

I understand that by signing the attached form I am agreeing to be aligned under the downstream agent hierarchy of the above mentioned General Agency (GA). I may not have to align all segments of Humana business under the designated GA and it is my responsibility to determine which lines of business are affiliated with the above GA.

Please note this is not a Delegated Commission Assignment Form and does not affect commissions.

Agent or Agency Name*

SAN*

NOTE: If you are unsure of your Humana SAN number, please contact Humana Agent Support directly at (800) 309-3163 and they can provide it to you.

Address*

Street Address, City ST Zipcode

Phone Number*

Area CodePhone Number

Email*

example@example.com

Indicate below which segment(s) of business this affiliation applies to:

Dental & Vision (Initial):

Clear

Medicare (Initial):

Clear

Achieve Med Supp (Initial):

Clear

Are you the Principle Officer of an agency currently contracted with Humana?*

YesNo

If yes, please provide the name and SAN/TIN to re-align the agency:

Agency Name

Agency SAN/TIN

IMPORTANT: If an agency is being released and receives commisions on behlf of any agent, each agent must submit an MGA assignment form in addition to the agency. If there are agents who are not realigning with the agency, a Delegated Commission Assigment Form must be submitted to update their payee. Failure to do so could prevent or delay the processing of this request.

I understand that if I would like to discontinue my relationship with the above GA at any time, I will need to follow the Agent Release Policy as outlined in the Producer Partnership Plan.

Agent/Agency Name*

Agent/Agency SAN*

Agent Signature*

Clear

Signature Date*

Date

SMA Signature Date*

Date

By selecting the "SUBMIT" button, I understand that I will not only receive a copy of my submission to the address I have listed above, but my submission will also be sent, on my behalf, to Humana at agentsupport@humana.com for processing.

Humana Release (if applicable)

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