(FIELDS MARKED WITH * ARE REQUIRED)
Empower Brokerage Recruiter (if known)
First Name *
Last Name *
Best Contact Phone *
—Please choose an option—ALAKARAZCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVIVAWAWVWIWY
NPN (National Producer Number) *
Residence State License # *
What is your product focus?
Individual HealthMedicare AdvantageMedicare SupplementsLife & FinancialSupplementalGroup
Do you use a smart phone or tablet?
—Please choose an option—YesNo
Are you currently working under another FMO or Agency?
—Please choose an option—YesNo
Please tell us about your other Agency or FMO affiliations.
How do you want to be paid commissions?
To receive advances, you must complete the following within 5 business days of requesting your first carrier:
Complete the Advances Form and return it to Fax (817) 410-5999.
Compete the online Agent Orientation class inside Empower University. (once you have a login)
*If you do not complete these within 5 business days of requesting your first carrier, you will automatically be set to "As Earned" and your contracting will proceed.
Any comments? Just let us know.
Thank you! The answers to these questions will better help us determine the fastest way to get you up and running with Empower Brokerage.
AGREEMENT: 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. I agree that I am the current authorized user of the phone number and e-mail address submitted. I expressly consent to opt in to receive e-mails and text messages from Empower Brokerage about health insurance, life insurance, Medicare Supplements, Medicare services and other options. Empower Brokerage is an independent insurance agency and is not affiliated with the federal Medicare program. By clicking and submitting this form, I understand that I am enrolling in an ongoing marketing campaign by Empower Brokerage, and I will receive text messages and e-mails as part of the ongoing Empower Brokerage marketing campaign. By clicking and submitting this form, I am authorizing Empower Brokerage to provide my information to a licensed agent, and I am authorizing the agent to contact me. I am also authorizing the agent to call, e-mail, or text me at the phone number and email address I provided (even if that phone number is on any Do Not Call Registry or is a mobile number). I am consenting to calls with Empower Brokerage being recorded and monitored.
Standard text and data rates may apply. You can opt out of receiving text messages from Empower Brokerage at any time by replying to an Empower Brokerage text message with “unsubscribe”, “stop”, “end”, “no”, or “opt out”. If you want to opt out of receiving future e-mails from Empower Brokerage, then you can do so at any time. Please click the “unsubscribe” button in our e-mail. Empower Brokerage values your privacy and will not share your personal information with any other business or persons.
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