B2B Carrier Request Form

B2B Carrier Request Form
Do not complete this form if the upline is not contracted.

Please note: If an upline within the hierarchy does not hold an active agent code at the carriers selected we are unable to move foward with certain requests.
Date

MonthDayYear
Date
What type of request?*

Carrier AdditionNew Agent Request
Agency*
Agency Email*
example@example.com
Agent Name*

First NameLast Name
Agent's Email*
example@example.com
Direct Upline*

First NameLast Name
New Business Submitted?*

YesNo
What carriers need pre-appointment? (Other option require carrier name/s)*

American Amicable (QSP)AmericoAtheneCorebridge/AIG (GIWL/SIWL)Corebride/AIG (Term)F&GForestersLafayetteLGA (Quility Term Plus)LibertyMutual of OmahaMutual Trust (PAAC)Mutual Trust Vista IUL (PALIC)NationwideNLGNorth AmericaPacific LifeRoyal NeighborsSBLI-QLTTransamericaUHLOther
Are commission levels going to be all the same or varied for carriers?*

SameVaried
What level do you want for the carriers?*
American Amicable (QSP): What level for this carrier?*
Americo: What level for this carrier?*
Athene: What level for this carrier?*
Corebridge/AIG (GIWL/SIWL): What level for this carrier?*
Corebridge/AIG (Term): What level for this carrier?*
F&G: What level for this carrier?*
Foresters: What level for this carrier?*
Lafayette: What level for this carrier?*
LGA (Quility Term Plus): What level for this carrier?*
Liberty: What level for this carrier?*
Mutual of Omaha: What level for this carrier?*
Mutual Trust (PAAC) : What level for this carrier?*
Mutual Trust Vista IUL (PALIC): What level for this carrier?*
Nationwide: What level for this carrier?*
NLG: What level for this carrier?*
North American: What level for this carrier?*
Pacific Life: What level for this carrier?*
Royal Neighbors: What level for this carrier?*
SBLI-QLT: What level for this carrier?*
TransAmerica: What level for this carrier?*
UHL: What level for this carrier?*
Other: What level for this carrier?*
Notes
Quility Account Manager*
Quility Account Manager Email
example@example.com
Should be Empty: