"*" indicates required fields Δ Thanks for your interest in contracting with ICT Insurance Group. Complete the information in the form below, and our team will reach out to you with contracting instructions.Questions? Call us at (316) 440-6111Status* New Lasting Mark Agent Current Lasting Mark AgentName (as it appears on your license)* First Name Middle Name Last Name Nickname/Preferred NameMailing Address* Street Address Street Address Line 2 City State Zip Code Mailing Address Type* Residence BusinessPrimary E-mail* Enter Email Confirm Email Cell Phone Number*Secondary Phone NumberNPN*Resident State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAre you requesting to appoint as an individual or an agency?* Individual Agency Both Individual and AgencyAgency Name*What level of agency will you be?* 1 2 3 4 5 6Are you the principal agent for this agency?* Yes NoAgency NPN*Agency/Manager Affiliation*Enter ICT if you are not working with a specific manager or agency.Direct Upline ManagerHierarchy or Commission ChangesACA LevelCONTRACT REQUESTSClick the grey bars below to see all carriers available in that segment. Select the carriers you would like to request appointment with, and our contracting team will send you instructions for new appointments & transfers.NOTE: Selecting carriers below indicates intent to contract; you will not be fully contracted until you complete all required paperwork/links for each carrier.Under 65 - Individual Under 65 - Individual Click here to see which ACA carriers are available by state.ACA Carriers:Ambetter - (KR) New Appointment Transfer Add state(s)Select the states that you're requesting to appoint with Ambetter:* AL AZ AR DE FL GA IA IL IN KS KY LA MI MS MO NE NH NJ NC OH OK PA SC TN TX WAAmbetter transfers will close September 1st - April 15thChristus (DB)TX, LA Only New Appointment Transfer Add state(s)Select the states you are requesting to be appointed to sell Christus:* TX LAUnited Healthcare (ACA) - (DB) New Appointment Transfer Add state(s)Select the state that you are requesting to be appointed to sell United Healthcare:* AL AZ CO FL GA IN IL IA KS LA MD MI MO MS NC NE NJ NM OH OK SC TN TX VA WA WI WYHave you completed your FFM Certification?* Yes NoNote: All agents marketing ACA health plans are required to take the CMS (FFM) Certification. Most ACA carriers require agents to have this certification completed prior to contracting. Questions? Call our Agent Care Team at (316) 440-6111This form is NOT a contract and you must complete contracting paperwork and be appointed before you start selling/marketing any carrier products:* By clicking "Submit" I understand that this form is not a contract and does not appoint or certify me to sell/market any carrier products. This is a contract request form to indicate my interest in appointing through ICT Insurance Group, and I am requesting contracting information for the carriers selected on this form. I understand that I will be receiving contracting links and emails for each carrier selected on this form, and I will not be ready to sell/market with these carriers until I complete each carrier's contract, complete any applicable certifications and the carrier has approved my appointment.Consent* By clicking Submit I provide my electronic signature expressly consenting to recurring contact from ICT Insurance Group regarding ICT Insurance Group’s contracts and training at the phone numbers end email address I provided. Messages may come to me via live, automated or prerecorded telephone call, text message, or email. I understand that my telephone company may impose charges on me for these contacts, and I am not required to enter into this agreement as a condition of purchasing property, goods, or services. I understand that I can revoke this consent at any time.*SMS Messages I consent to receive marketing text messages from ICT Insurance Group at the phone number provided. Frequency may vary. Messages & data rates may apply. Text HELP for assistance, reply STOP to opt out. I consent to receive non-marketing text messages from ICT Insurance Group about my order updates, appointment reminders etc. Message & data rates may apply.Terms of Service & Privacy PolicyCAPTCHA