Online Consent to Contract Form

Additional Comments, Concerns, or Questions:

Current Proof of E&O Insurance - Required

Resident State Life, Accident, Health License - Required

If requesting life products, please attach a copy of your current AML certificate

Additional Documents if Needed

If you are interested in appointing with any of the carriers listed below, we will also need a voided check to facilitate payments.
Anthem, Devoted (Upper-Level only), Excellus BCBS, Geisinger, Highmark Inc., Humana (Upper-Level only), UPMC or Wellcare.

Voided Check - if Needed

Must hold BOTH a Business Entity and Individual LAH License to complete below

Authorization Acknowledgement
By submitting this form you agree to hereby authorize CareValue, LLC, and its general agency customers (the “Authorized Parties”) to affix or append a copy of my signature to any and all required signature fields on forms and agreements of any insurance carrier (a “Carrier”) designated by me through the AllRep software or through any other means, including without limitation, by e-mail or orally. The Authorized Parties shall be permitted to complete and submit all such forms and agreements on my behalf for the purpose of becoming authorized to sell Carrier insurance products. I hereby release, indemnify and hold harmless the Authorized Parties against any and all claims, demands, losses, damages, and causes of action, including expenses, costs and reasonable attorneys' fees which they may sustain or incur as a result of carrying out the authority granted hereunder. By my submission of this form, I certify that the information I have submitted to the Authorized Parties is correct to the best of my knowledge and acknowledge that I have read and reviewed the forms and agreements which the Authorized Parties have been authorized to affix my signature. I agree to indemnify and hold any third party harmless from and against any and all claims, demands, losses, damages, and causes of action, including expenses, costs and reasonable attorneys' fees which such third party may incur as a result of its reliance on any form or agreement bearing my signature pursuant to this authorization.