Appointment Process Producer Profile

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Appointment Process Instructions

• Complete the following Producer License and Appointment Questionnaire Form.
• Answer all fields as accurately and as completely as possible.
• Click the submit button to have this form sent to your Regional Director for review.

Other Requirements

• You must attend a training class in person in order to be appointed as an individual sales producer. 
• A separate profile is required for all agencies and producers.
• If an agency already has a BCBSLA appointment 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 appointed, 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 appointment requests for individual sales from out-of-state producers.

Status Change Instructions

• Update only the fields that you need to change.
• Click the submit button to have this form sent to your Regional Director for review.

	Producer License & Appointment Questionnaire Type of appointment requested: Individual Producer Individual & Group Producer Farm Bureau Shelter Agent       Group Producer Met Life PS Team Preferred Producer Contract is in the name of: Agency Producer Information: Agency or Producer Name: Will commissions be assigned to someone other than the name listed above? Yes No Agency Name: (complete only if commissions will be assigned) Business Street Address:   (All correspondence will be sent to this address, unless otherwise requested.) City: State: Zip: Business Phone: Home Phone: Cell Phone: Fax: E-Mail: Date of Birth:  (ex. 01/01/2006) Sex: Male Female LA Insurance License Number: License Is: Individual Partnership Corporate Has this insurance license ever been revoked or suspended? Yes No   If yes, please explain: Have you ever been appointed with the Blue Cross and Blue Shield of Louisiana? Yes No   If yes, what was your old producer number? Number of Producing Agents (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 an appointed producer for Blue Cross and Blue Shield of Louisiana: 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 appointed 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 an appointment 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 appointed 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 is 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.