Producer Contracting

This information will be submitted to BCBSIL for contracting.

Fields marked with a  *  are required.

Producer Information


Background Information


Has your license to sell insurance or HMO products ever been denied, suspended or revoked in any state?
Have any complaints been filed against you with any insurance regulatory board, agency or department of insurance within the last five years?
Have you ever been denied appointment or renewal appointment by any insurance and/or managed care company?
Have you ever been a party to a lawsuit relating to insurance or managed care coverage?
Have any settlements ever been made on your behalf?
Are there any claims or lawsuits presently pending against you?
Have you ever been convicted of a crime other than minor traffic violations?
Are you indebted to any policy holder or insurance company or managed care company?
Is there any objection to an inspection report at HCSC'S expense?

E-Signature


The above information will be used to complete contracting on your behalf, including electronic signatures.