B2B Carrier Request Form

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

No contracts can be sent until all the hierarchy is contracted with a code.
What type of request?*

Carrier AdditionNew Agent RequestCommission/ Hierarchy/ Annualization Change
Agency Owner Full Name*
Agency Owner Email*
example@example.com
Upline Full Name (who is this agent direct to?)*
Upline Email*
example@example.com
Agent Full Name*
Agent's Email*
example@example.com
Agent's Resident State*
New Business Submitted?*

YesNo
Date App Signed*

MonthDayYear
Date
What proprietary products need pre-appointment?

AmAm : QSPLGA : QLT+SBLI : QLTForesters : Live Well (Coming Soon)F&G : Quantum IUL (Coming Soon)UHL : QSFG (Quility Secure Future Guaranteed) (Coming Soon)
What carriers need pre-appointment?*

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
Notes
Nationwide: What level for this carrier?*
Corebride/AIG (Term): What level for this carrier?*
UHL: What level for this carrier?*
Royal Neighbors: What level for this carrier?*
American Amicable (QSP): What level for this carrier?*
Corebridge/AIG (GIWL/SIWL): What level for this carrier?*
Americo: What level for this carrier?*
Americo: What level for this carrier?*
Mutual Trust Vista IUL (PALIC): What level for this Carrier?*
Athene: What level for this carrier?*
Athene: What level for this carrier?*
Liberty: What level for this carrier?*
F&G: What level for this carrier?*
F&G: What level for this carrier?*
Foresters: What level for this carrier?*
Foresters: What level for this carrier?*
Mutual Trust (PAAC): What level for this carrier?*
Lafayette: What level for this carrier?*
Lafayette: What level for this carrier?*
LGA (Quility Term Plus): What level for this carrier?*
Mutual of Omaha: What level for this carrier?*
Mutual of Omaha: What level for this carrier?*
NLG: What level for this carrier?*
NLG: What level for this carrier?*
North American: What level for this carrier?*
North American: What level for this carrier?*
Pacific Life: What level for this carrier?*
Pacific Life: What level for this carrier?*
SBLI-QLT: What level for this carrier?*
SBLI-QLT: What level for this carrier?*
Transamerica: What level for this carrier?*
TransAmerica: What level for this carrier?*
Other: What level for this carrier?*
Other: What level for this carrier?*
Quility Account Manager*
Quility Account Manager

First NameLast Name
Quility Account Manager Email
example@example.com
Should be Empty: