First Name
Last Name
Phone Number
Email
State—Please choose an option— AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY
City
NPN (National Producer Number)
Residence State License #
Empower Brokerage Recruiter (if known)
What is your product focus?
Individual Health Medicare Advantage Medicare Supplements Life & Financial Supplemental Group
Do you use a smartphone or tablet?
Yes No
Are you currently working under another FMO or Agency?
Yes No
Please tell us about your other Agency or FMO affiliations
How do you want to be paid commissions?
As Earned Advances
To receive advances, you must complete the following within 5 business days of requesting your first carrier:
Complete the Advances Form and return it by fax to (817) 410-5999. Download Here
Complete the online Agent Orientation class inside Empower University.
Any comments? Just let us know
By checking this box, you consent to receive text messages from Empower Brokerage and/or a licensed Empower Brokerage agent. These messages may include marketing messages (e.g., promotions, reminders) and follow-up communications related to your inquiry to the number provided, which may include the use of an autodialer. Message and data rates may apply. Message frequency varies. You can unsubscribe at any time by replying STOP or clicking the unsubscribe link.
By clicking and submitting this form with my name, phone number, and e-mail address, I agree that I am at least 18 years of age. By clicking and submitting this form, I understand that I am enrolling in an ongoing marketing campaign about insurance services and other options from Empower Brokerage or a licensed agent, and I will receive phone calls and e-mails (even if that phone number is on any Do Not Call Registry or is a mobile number). If you want to opt out of receiving future e-mails from Empower Brokerage, you can do so at any time by clicking the “unsubscribe” button in our e-mail.
Terms and Conditions and Privacy Policy .
