Congratulations!! Your decision to move to the next step is among the smartest decisions you will made. To maintain the momentum complete the application form below. The more complete your application the better we'll be able to evaluate your qualifications and allow you to continue your journey to a better lifestyle with Assurecor!
Personal Data
First Name:
Last Name
Address
City
State
Zip Code
Daytime Phone (XXXXXXXXXX)
Home Phone (XXXXXXXXXX)
Cell Phone (XXXXXXXXXX)
Email Address

License Information

Are you now licensed for Life, Accident and Health?
If so, in what states are you licensed?
Have you sold health insurance previously?
If so, for what organization?
List companies with which you are currently appointed?
How many years have you been selling health insurance?
National Producer Number (click here to lookup)
Do you have management experience?
If so, with what organization?
Are you currently managing agents?
If so, how many agents?
Any additional information?





Saving Money for Families and Small Businesses

  • Health plans as low as $89 per month
  • Traditional Major Medical or New Fixed Indemnity Health Plans.
  • Life Insurance, Cancer, Critical Illness, Medicare, Long Term Care and other Supplemental Coverage.
  • Flexibility.  Freedom to choose from a wide array of policies and benefit options.
  • Preexisting Conditions Health Insurance
  •  Freedom to choose your providers without a referral.
  • Health Plans with No Deductibles, No Co-Insurance and No Co-Pays.
  • Dental Insurance as low as $15.50.
 

Areas of Practice

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    877-778-5116