Step 1 First Name Last Name Phone Number Email State —Please choose an option—ALAKARAZCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVIVAWAWVWIWY City NPN(National Producer Number) Residence State License # Empower Brokerage Recruiter (if known) Next Step 2 What is your product focus? Individual HealthMedicare AdvantageMedicare SupplementsLife & FinancialSupplementalGroup What is your product focus? Individual HealthMedicare AdvantageMedicare SupplementsLife & FinancialSupplementalGroup Do you use a smart phone or tablet? YesNo Are you currently working under another FMO or Agency? YesNo Please tell us about your other Agency or FMO affiliations. BackNext Step 3 How do you want to be paid commissions? As EarnedAdvances 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. Download Here 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. 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. For more details, see our Terms and Conditions and Privacy Policy. 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. Back
