IMC - PIF/Aetna/UHC Contract

New Producer Information Form and Contract Request (Aetna & UHC)

for agents of IMC (Insurance Marketing Center)
In order to provide the best possible service to our agents and their downlines, please complete this simple information form so that you are properly set up in our system prior to starting your contracts.

If you choose Aetna below, submitting this form will redirect you to the Aetna contracting website. If you choose UHC, you will receive and email invitation to begin the UHC contract.

If you choose both, you will receive the UHC email as well as be directed to the Aetna contracting website.
APPOINTMENT TYPE *

Individual Corporation (Principal Only)
Your General Agent/Upline *
Agent Name *

First Name Last Name
Date of Birth *

Month Day Year
NPN *
Agency Name (if applicable)

Business Address *

Home Address

E-mail *
Do you have a website? *

Yes No
Website *
Preferred Phone Number *

- Area Code Phone Number
Additional Phone Number

- Area Code Phone Number
Fax Number

- Area Code Phone Number
I want to contract with:

Aetna EnvisionRxPlus Humana Silverscript UnitedHealthcare
IMPORTANT INFORMATION to Complete the Aetna Contract:

Aetna uses the No More Forms Platform for contracting.

Once logged into No More Forms you will need Client Package Code 9TG3SPAG4 which is a required piece of information for the contracting process.

RETURNING No More Forms Users: (for ANY CARRIER) use your existing No More Forms Login and Password

NEW No More Forms Users: Create a new No More Forms Account
Contact us with any questions: 301-468-8888
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New Producer Information Form and Contract Request (Aetna & UHC)