Blueprint Health Agency — Agent Onboarding

Agent Onboarding Form

Complete all sections to begin contracting and receive payment

Section 1 of 8 13% complete
Personal information
Basic identity details required for licensing and contracting.
First name *
Required
Middle name
Last name *
Required
Alias / other names used or licensed under
Name on resident state insurance license *
Required
Date of birth *
Required
Gender *
Race / ethnicity *
Languages for business *
Are you or spouse a US veteran? *
If yes, branch of service
Citizenship & identification
Required for state licensing and background verification.
US citizenship status *
Country / state of birth *
Required
USCIS # (if non-citizen)
USCIS status expiration
Social Security Number *
Required
Driver's license number *
Required
Driver's license state
Upload driver's license *
Click to upload driver's license — JPG, PNG, or PDF
Insurance license information
Your NPN, resident state license, and Blueprint start date.
NPN (National Producer Number) *
Required
Resident state license number *
Required
Resident license state *
Required
Blueprint Health starting date *
Required
Upload insurance license *
Click to upload insurance license — JPG, PNG, or PDF
Contact & address
Current contact info and residential address.
Phone number *
Required
Is this a Mobile or Landline? *
Personal email *
Required
Business email
Street address *
Required
City *
Required
State *
Required
ZIP code *
Required
County (not country) *
Required
Date moved to current address *
Required
Address matches resident license? *
If you have lived at your current address less than 2 years, provide your previous address below including county and move-in date.
Previous address (if less than 2 years at current)
Tax information & direct deposit
W-9 compliance and commission payment setup.
Paid as individual or business entity? *
Business name (if entity)
EIN (if entity)
Entity type
Upload completed W-9 *
Click to upload W-9 — PDF preferred
Direct deposit / banking
Account holder name *
Required
Bank name *
Required
Account type *
Routing number *
Required
Account number *
Required
Upload voided check or bank confirmation
Click to upload — PDF, JPG, or PNG
Employment history — past 5 years
Required for state licensing compliance.
Full information required to maintain and buy state licenses. Start with your most current position. Include part-time, full-time, self-employment, military, and education. Any gap over 30 days must be covered — mark as Unemployed or Student. Email any additional history to [email protected]
Position 1 — most recent *
Start (MM/YYYY)
End (MM/YYYY or Present)
Company / School / Unemployed / Student
Title / Position / N/A
City + State
Position 2
Start (MM/YYYY)
End (MM/YYYY)
Company / School / Unemployed / Student
Title / Position / N/A
City + State
Position 3
Start (MM/YYYY)
End (MM/YYYY)
Company / School / Unemployed / Student
Title / Position / N/A
City + State
Position 4
Start (MM/YYYY)
End (MM/YYYY)
Company / School / Unemployed / Student
Title / Position / N/A
City + State
Position 5
Start (MM/YYYY)
End (MM/YYYY)
Company / School / Unemployed / Student
Title / Position / N/A
City + State
Position 6
Start (MM/YYYY)
End (MM/YYYY)
Company / School / Unemployed / Student
Title / Position / N/A
City + State
Position 7
Start (MM/YYYY)
End (MM/YYYY)
Company / School / Unemployed / Student
Title / Position / N/A
City + State
Background questions
Required for all carrier contracting and state licensing.
Please answer honestly — states and carriers find things.
Government law enforcement agencies still have access to your criminal records even if they have been sealed and/or expunged. If you answer Yes to any question, please email court documents and a signed and dated explanation for each occurrence to Blueprint Licensing.
1. Misdemeanor conviction, deferred judgment, or current misdemeanor charge? (Includes DUI/DWI, driving without license, reckless driving, suspended/revoked license. Excludes juvenile adjudications.) *
2. Felony conviction, deferred judgment, or current felony charge? (Excludes juvenile adjudications.) *
3. If felony conviction involving dishonesty or breach of trust — applied for written consent under 18 USC 1033? *
If yes above — was 1033 consent granted?
4. Military offense conviction, deferred judgment, or current military charge? *
5. Ever named in an administrative proceeding / FINRA sanction / arbitration regarding a professional license or registration? *
6. Ever investigated, suspended, or terminated by CMS? (Answer Yes even if cleared or reinstated.) *
7. Any demand, judgment, or bankruptcy against you or your business for overdue monies? (Include personal bankruptcies.) *
8. Party to or found liable in any lawsuit/arbitration involving fraud, misrepresentation, or breach of fiduciary duty? *
9. Ever had an insurance agency contract terminated for alleged misconduct? *
10. Child support obligation in arrearage? *
If yes — months in child support arrearage
If yes — in compliance with repayment agreement?
If yes — subject of child support subpoena or warrant?
If you answered Yes to any question above — supporting docs submitted to NIPR?
Acknowledgment — failure to answer honestly or intentionally omit information can be grounds for termination *
Emergency contact
Optional but recommended.
Emergency contact name
Relationship
Emergency contact phone
Attestation
  1. I hereby certify that, under penalty of perjury, all of the information submitted in this application and attachments is true and complete. I am aware that submitting false information or omitting pertinent or material information is grounds for license revocation or denial and may subject me to civil or criminal penalties.
  2. Unless provided otherwise by law, I hereby designate the Commissioner, Director or Superintendent of Insurance in each jurisdiction for which this application is made to be my agent for service of process regarding all insurance matters.
  3. I grant permission to verify information with any federal, state or local government agency, current or former employer, or insurance company.
  4. I certify, under penalty of perjury: a) I have no child-support obligation, b) I have a child-support obligation and am currently in compliance, or c) I have identified my child support arrearage on this application.
  5. I authorize the jurisdictions to give any information concerning me as permitted by law to any federal, state or municipal agency and release them from all liability for furnishing such information.
  6. I acknowledge that I understand and will comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure.
  7. For Non-Resident License Applications, I certify that I am licensed and in good standing in my home state/resident state for the lines of authority requested.
  8. I hereby certify that upon request, I will furnish certified copies of any documents attached to this application or requested by the jurisdiction(s).
Signature — type your full legal name *
Signature required
Date signed *
Required

Onboarding submitted!

Thank you! Your information has been received by Blueprint Health Agency.
You will be contacted shortly with next steps.