Producer Profile

FOR PRODUCERS

Producer Profile

Contracting Process Instructions

Complete the following Producer Questionnaire.
Answer all fields as accurately and as completely as possible.
Click the submit button when complete.

Other Requirements

You must attend a training class in person in order to be contracted as an individual sales producer.
A separate profile is required for all agencies and producers.
If an agency already has a BCBSLA contract and would like to add a producer, then a profile is required only for the new producer.
If an agency is requesting to be newly contracted, please complete a profile in the name of the agency and separate profile in the name of each new producer indicating that commissions will be assigned.
We are not accepting contracting requests for individual sales from out-of-state producers.

* indicates required field

Type of Request
New
Change to existing contract

Type of contract requested
Individual Producer Shelter Producer PS Team
Individual and Group Producer Group Producer Preferred Producer
Farm Bureau

Contract is in the name of
Agency
Producer

Information

Producer Name
*

If this is a producer contract request, will commissions be assigned to someone other than the name listed above?
Yes
No

If yes, Agency Name

Name of Authorized User

Business Street Address
*
(All correspondence will be sent to this address, unless otherwise requested.)

City
*

State
*

Zip Code
*

Business Phone
*

Cell Phone

Fax

E-Mail
*

Confirm E-Mail Address
*

Date of Birth

Open the calendar popup.

Tax ID or Social Security Number
*

Sex
Male
Female

Race of business owner or producer
African American
Asian
Caucasian
Hispanic
Other
Unspecified

LA Insurance License Number
*

Has this insurance license ever been revoked or suspended?
Yes
No

If yes, please explain

Have you ever been contracted with Blue Cross and Blue Shield of Louisiana?
Yes
No

If yes, indicate producer number

Number of active producers (in agency)

Property Casualty

Life/Health

Top Three Life and Health Companies Represented

Companies Represented	Annual Written Premium Volume	Years Represented

Specific reasons for wanting to become a contracted producer for Blue Cross and Blue Shield of Louisiana: *

Name of BCBSLA contact (if applicable)

The Federal Insurance Fraud Provisions of the Violent Crime Control Act make it a criminal offense for Blue Cross and Blue Shield of Louisiana to willfully permit any person who has been convicted of insurance fraud or felony involving dishonesty or breach of trust to be employed by Blue Cross and Blue Shield of Louisiana or contracted as a producer.

Have you ever been convicted of insurance fraud or of a felony involving dishonesty or a breach of trust? *
Yes
No

If yes, please give details

Completion of this form does not constitute a contract as a producer for Blue Cross and Blue Shield of Louisiana. Applicant should be informed that to be/become a Blue Cross and Blue Shield of Louisiana contracted producer to sell individual products, some training may be required.

I certify that all of the above information is correct to the best of my knowledge. I understand that any misrepresentation made on my part may be grounds for termination of my contract and/or appointment(s) with Blue Cross and Blue Shield of Louisiana and its subsidiaries.

Submit

Please press the Submit button only once to have this form sent.

External links open in new windows to websites not controlled by BCBSLA.

DOI

Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association. Copyright © 2010 Blue Cross and Blue Shield of Louisiana. Blue Cross and Blue Shield of Louisiana is licensed to sell products only in the state of Louisiana.

FOR PRODUCERS