Producer Profile Form | Producers | Blue Cross and Blue Shield of Louisiana

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.

Producer Information

Producer First/Last Name

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

Yes

If yes, Agency Name

Name of Authorized User

Business Street Address 1

Business Street Address 2

City/State/ZIP

Business/Cell/Fax Number

Home Street Address 1

Home Street Address 2

City/State/ZIP

Email/Confirm Email

Date of Birth

Tax ID or Social Security Number

Gender

Male

Female

Race of business owner or producer

African American

Asian

Caucasian

Hispanic

Other

Unspecified

Producer Information (cont.)

LA Insurance Number

Has this insurance license ever been revoked or suspended?

Yes

If yes, Please explain

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

Yes

If yes, producer number

Number of active producers in agency (property casualty and life/health)

Top Three Life and Health Companies Represented (company name/annual written premium volume/years represented)

Specific reason for wanting to become a contract producer for Blue Cross and Blue Shield of Louisiana

Name of BCBSLA contact

Agency Point of Contact

An Agency Point of Contact is required to review the list of users on an annual basis and remove access as needed. This individual will not have access to the AccessBlue portal unless they are also identified as a Producer or Superuser.

Agency Point of Contact

Agency Point of Contact Email Address

Agency Point of Contact Preferred Phone Number

Producer Superuser or Agency Superuser

The Producer Superuser or Agency Superuser will receive access to all enrollment, billing, coverage, eligibility, reporting tools, eQuoting and Individual Enrollment. The Superuser is responsible for creating and managing additional delegate user accounts in the portal.

Producer Superuser or Agency Superuser First/Last Name

Superuser Email Address

Superuser Preferred Phone Number

I hereby certify the Producer Superuser or Agency Superuser listed above will create delegates for the producer or agency as well as deactivate users when they are no longer employed.

Producer or Agency Point Of Contact

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?

Yes

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.

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.

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Customer Service

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Sales

855-343-0361

Medicare Options

800-232-4967

Contract Information

Producer Information

Producer Information (cont.)

Agency Point of Contact

Producer Superuser or Agency Superuser