Start your contracting request

Thank you for your interest in joining our team! Please complete this form to begin contracting with Axxess Benefit Consultants. Fields marked with * are required.

Personal Information

First name *Last name *

Email address *Phone number *

Agent NPN (National Producer Number) *Date of birth *

Social Security Number *

Address

Resident address (line 1) *

City *State *ZIP code *

Licenses

Add your resident license and any non-resident state licenses.

TypeResident state *

Resident license number *Expiry date

Agency

This section must be completed if you are contracting your own licensed agency. If you do not have your own licensed agency, you may skip this section.

Agency nameAgency NPN

Agency License NumberTax ID / EIN

E&O Insurance

E&O Insurance CarrierOptionalE&O Policy Limit

Agent Status

Are you currently employed as a captive agent? *

Relationship

Referred By (optional)Who told you about Axxess? This may or may not be your contracting upline/agency owner.If you are transferring from an existing agency, who is your current upline?

Carriers Requested

Open only the product lines you want. ACA is not required unless you open that section.

Document Upload

Supporting Documentation (Optional)Upload any relevant supporting documents — E&O certificate, AHIP certificate, or release documents. You may also submit these after your request is received. Accepted: PDF, JPG, PNG. Max 25MB.