Baylor Scott and White Health Plans

Please complete and submit the form below with the attached documents.

Download and complete the following documents and upload them using the form below.

• Mandatory Check Deposit Authorization (managers only)
• W-9 (all agents and managers)
• Independent Producer Agreement (all agents and managers)
• FFM Regulatory Compliance Addendum (all agents and managers)

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Email(Required)

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Carrier

Carrier

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Upline Direct Manager(Required)

Upline Direct Manager

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Upline GA

Upline GA

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Upline MGA

Upline MGA

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Upline FMO

Upline FMO

Name(Required)

Your name as it appears on your insurance license

First Last

Birth Date(Required)

Birth Date

MonthMonth123456789101112

DayDay12345678910111213141516171819202122232425262728293031

YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Agent NPN(Required)

Agent NPN

Agent SSN (No dashes)(Required)

Agent SSN

Address(Required)

Agent Resident Address

Street Address City State / Province / Region ZIP / Postal Code

Cell Phone(Required)

Cell Phone

Other Phone

Other Phone

Check Deposit upload(Required)

Upload Check Deposit (EFT) Form

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

W-9 upload(Required)

Upload your completed W-9 Form

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

Agent Agreement upload(Required)

Upload your completed Agent Agreement

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

FFM Reg Compliance Addm upload(Required)

Upload your completed FFM Regulatory Compliance Addendum

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.