Contracting Request - UCLA - Berwick

AGA UCLA Health Medicare Advantage - Request Form
Thank you for your interest in contracting with UCLA Health Medicare Advantage. AGA has partnered with our Integrity Partner, Berwick, to offer this carrier to our agents.

Please follow the steps below to become ready to sell.

1. Submit the UCLA Contracting Request via JotForm. Please have your CA license, individual E&O, AHIP, and void check ready for upload.

2. You will receive a contract using Adobe Sign. The email will be from adobesign@adobesign.com.

3. You will receive the UCLA certification link from UCLAcontracting@berwickinsurance.com

4. After certifications are complete, a Federal and State Exclusion check will be performed.

5. After the exclusion check is passed, you will receive your RTS notification.
Agent Full Name*

First NameMiddle NameLast NameSuffix
Agent Email*
example@example.com
Agent NPN*
Agent Phone*
Agent CA DOI License Number*
Preferred Language*
FLUENT Languages*
Other Fluent Languages-Specify
Carrier Selection
Carrier Request(s)*

UCLA - Agent Level
Commission Payment Type*

Commissions paid to meCommission is paid to a corporation I ownCommission is paid to a corporation I do not own
Upload your individual CA license*

Cancelof
Upload your individual E&O*

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Upload your 2025 AHIP*

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Upload a void check*

Cancelof
Should be Empty:

AGA UCLA Health Medicare Advantage - Request Form