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

  • 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.
* indicates required field
Type of Request


Type of contract requested



Contract is in the name of


Information
Producer Name
*
If this is a producer contract request, will commissions be assigned to someone other than the name listed above?

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
*
Tax ID or Social Security Number
*
Sex

Race of business owner or producer






LA Insurance License Number
*
Has this insurance license ever been revoked or suspended?

If yes, please explain

Have you ever been contracted with Blue Cross and Blue Shield of Louisiana?

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? *

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