American Community understands the critical role agents and brokers play in the sale and service of health insurance products.

As an American Community agent, you’ll receive the support of our marketing directors, national sales office staff and outstanding customer service teams throughout the Company. 

Thank you for your interest in contracting with American Community. We are contracting agents on a select basis. Only aggressive, proven, life, health, and group producers will be considered.

Note: This is a licensing request form, not a licensing application.

How long have you been a licensed agent?   Under 12 months 1-5 years 5-10 years 10+ years

Have you ever been contracted with American Community?    Yes     No        If yes, when?  Agent #

Do you have a current life and health license?    Yes     No        Number of years licensed

Do you carry errors and omissions (E & O) insurance?    Yes     No  (Required)

What life/health companies do you represent?

Production in the past 12 months: Individual health applications Individual health premium $ Group health cases written Group health premium $ Individual life applications Individual life premium $ I understand: Initials 1. American Community has a $10,000 minimum annual production requirement. 2. American Community requires its agents to be HIPAA-compliant. HIPAA forms will be mailed with the Agent Application and must be completed and returned with your application. 3. American Community will not recognize agent of record letters during an agent’s first contract year. Please indicate a reason for requesting a contract with American Community:

Thank you for your interest in American Community. Your information request form will be reviewed by our marketing staff. A marketing representative will contact you within 72 hours (excluding holidays).