Pilot Program Form Template

Thank you for your interest. Interview positions have been filled.
Attention Wynn Network Associates:

Mr. Wynn has been working diligently on finding new ways to keep WNA trailblazing in the forefront of the competition. WNA is about to take it to the next level with its new pilot program. If you are interested in becoming a part of the roll out Medicare Screening Pilot please answer the following questions and click submit or send your reply to Wynnrecruit@gmail.com

This invitation is extended to all active Wynn Network agents however, spaces are limited and all interested candidates will have to complete the pre-screen questionnaire below and schedule an in office face to face interview.
Full Name *

First Name Last Name
E-mail *
Cell Phone Number *

- Area Code Phone Number
Your Upline Manager *
Residence Lic. *
Res. License # *
Non-Residence State(s)
Please list all the carriers with whom you are contracted.
ACA Insurance Companies Appointed To? *

1. Humana 2. Aetna/Cov 3. BCBS GA 4. UH1 5. Harkin 6. Cigna 7. Ambetter 8. HAP (Corp) 9. Molina 10. BCBS SC 11. None
Medicare Insurance Companies Appointed To? *

1. United Healthcare 2. Aetna/Cov 3. Humana 4. BCBS GA 5. Cigna 6. Well Care 7. Centene 8. None
Which of those carriers are you NOT aligned with under WNA?
1. Have you reconciled all of your ACA book of business? *

Yes No
2. Have you reconciled all of your Medicare book of business? *

Yes No
3. Are you AHIP certified? *

Yes No
4. Can you write Medicare policies? *

Yes No
All appointments have been fille.

NOTE: Your selection does not confirm your appointment. You will be contacted confirming the available date and time of your appointment.
Requested Appointment Date *

Tuesday March 5 Friday March 8
Requested Appointment Time *

11:30am 1:00pm 1:30pm 2:00pm 2:30pm 3:00pm 3:30pm 4:00pm 4:30pm 5:00pm
Alternate Appointment Date *

Tuesday March 5 Friday March 8
Alternative Appointment Time *

11:30am 1:00pm 1:30pm 2:00pm 2:30pm 3:00pm 3:30pm 4:00pm 4:30pm 5:00pm
Should be Empty: