Contracting Request

BCBS TN Contracting Request
Thank you for your interest in contracting with BCBS TN. AGA has partnered with our Integrity Partner, Agent Pipeline, to offer this carrier to our agents. To get started, complete the BCBS TN Contracting Request. After a few days, you will receive a contracting link to finalize your contracting process.
Agent Full Name*

First NameMiddle NameLast NameSuffix
Agent Email*
example@example.com
Agent NPN*
Agent TN DOI License Number*
Agent Phone*
E&O Expiration Date

MonthDayYear
Date
Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How this appointment is to be paid?*

Commissions paid directly to meCommissions paid to a corporation I ownUpline – the agent is LOA to AGA
Corporation Name*
Corporation NPN*
Do you currently have, or have you ever had, a BCBS TN appointment?*

YesNo
If yes, how was that appointment paid?*

Direct – to the agentAgency – to the agent’s agencyUpline – the agent is LOA to another agency
Transferring agents need to complete the BCBS TN Transfer Form
Upload the completed BCBS TN Transfer Form*

Cancelof
Should be Empty:

BCBS TN Contracting Request