Humana MGA Assignment Form

Humana MGA Assigment Form

AGENT TO GENERAL AGENCY ASSIGNMENT FORM

General Agency Information

GA NAME: Continental Health Alliance

GA NUMBER: 988

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 an Agent Business Transferal 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 Code Phone Number

Email *

example@example.com

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

Humana One (Initial):

Clear

Medicare (Initial):

Clear

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

Yes No

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

Agency Name

Agency SAN/TIN

*If the agency receives commission on behalf of multiple agents, each agent must submit an assignment form. If there are agents who are not realigning, they must submit an ABT F to change their payee.

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 Name *

Agent SAN *

Agent Signature *

Clear

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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