Hosted Agent Application

Email Address *

Company *

Job Title *

Website URL *

Physical Address? (Used for GDPR Compliance) *

Which of the following best describes you? (Please select one)*

Agency Owner / Agency PrincipalIndividual Producer / Independent AgentCaptive AgentAgency Administration / AssistantNew Agent / Agent in TrainingIMO / FMOOther (Please Specify):

Which of the following do you / does your firm focus on? (Check all that apply) *

Medicare SupplementMedicare AdvantageMedicaidIndividual Markets / ACADual EligibleAncillary BenefitsLife InsuranceAnnuitiesFinancial Planning / RetirementNon-Senior HealthNon-Senior WealthOther (Please Specify):

Which of the above is your biggest area of focus?*

How is the majority of your business conducted?*
In-personTelephone (buying calls/leads)A blendOther (Please Specify):

Your NPN*

Agency NPN

If you are an individual producer, how many years have you been writing policies?

If you are an individual producer serving the Medicare market, approximately how many applications do you do during AEP?

If you are an individual producer, in which States are you licensed

If you are an agency owner or agency principal, how many members are in your team and/or downline?

If you are an agency owner or agency principal, in what states / regions do you operate?

Which of the following areas of business development are the most interest to you? Choose all that apply.*
Compliance / Compliance TechLead GenerationJoin New UplineGrow DownlineDeveloping New SkillsetsAgency Operations / Increasing EfficienciesSelling an AgencyNew Plans to Offer / SellValue-Add Offerings for ClientsSocial MediaOther (Please Specify):

For which Hosted Agent Program do you wish to apply?* (Learn More)
Individual Hosted AgentTeam Hosted Agent

If you selected the Team option above, approximately how many team members would be joining you?
<45 - 10>10

Would you like to receive information about our new Premium Hosted Agent ticket ($395) that offers exclusive lounge access, preferred seating, longer access to recorded sessions, and more? *
YesNo

I understand that if I am selected as a Hosted Agent, I will be required to join at least one sponsored session of my choice. Note: The list of participating sponsored sessions will be shared with me by show management three to four weeks from Medicarians Vegas 2026.*
YesNo

If you have any comments and/or questions, please feel free to share them here.
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Lastly if you were referred by someone, please share below.