HCSC (BCBS) Please complete the form and click Submit to request contracting. This field is hidden when viewing the formEmail(Required) This field is hidden when viewing the formCarrier(Required)This field is hidden when viewing the formUpline GA(Required)Upline GAThis field is hidden when viewing the formUpline MGA(Required)Upline MGAThis field is hidden when viewing the formUpline FMO(Required)Upline FMOCurrently contracted?(Required)Are you currently contracted with HCSC? Yes No HCSC (BCBS)(Required)Health Care Service Corporation (HCSC) - Please select any state(s) you would like to be appointed in: IL MT NM OK TX Agent or Agency?(Required)Will you be applying as an Agent or as an Agency? Agent Agency Agency Name(Required)Agency NameBusiness Tax ID(Required)Business Tax IDWill you be assigning your commissions?(Required)Will you be assigning your commissions? Yes No Name(Required)Name as it appears on your insurance license First Middle Last Address(Required)Address Street Address City State / Province / Region ZIP / Postal Code Cell Phone(Required)Cell PhoneBirth Date(Required)Birth Date MM slash DD slash YYYY Social Security(Required)Social SecurityAgent NPN(Required)Agent NPN
