Sole Proprietor Agency Agreement Required Documents
Sole Proprietors are independent agents who are in business for themselves (not incorporated) with no other agents selling for them. A Sole Proprietor typically conducts business under his/her Social Security Number as opposed to using a Tax Identification Number.
We must receive all required documents for Florida Blue to process your appointment. The list below will ensure you are submitting all required documents and signatures.
- Email this information to our office at ChannelPartnerDataManager@floridablue.com.
- You can also fax it to 1-904-997-5866.
- Send the Appointment Fee Invoice, along with a check or money order by U.S. mail to the address below.
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Sign and return page 1 to Florida Blue office. Sign and retain page 2 for your records. |
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Complete and return page 1 to Florida Blue office. Name and Tax ID# must match IRS records. |
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Errors & Omissions |
Please submit a copy of the Errors & Omissions Declaration Page or Certificate of Insurance. |
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Complete and return document to Florida Blue. Retain a copy for your records. |
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Complete and return document to Florida Blue. Retain a copy for your records. |
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Complete and return document to Florida Blue. Retain a copy for your records. |
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To be completed if you wish any office staff to have access to your agency information via phone or the Florida Blue website. |
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Agency owner(s) must sign this form. If there is more than one Agency owner, please submit a form for each owner. |
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Check or money order must be sent by U.S. mail for set-up to be completed. Mail to address below. |
Please mail the Appointment Invoice to:
Florida Blue
CPIM – Agent Appointment
4800 Deerwood Campus Parkway, DC2-6
Jacksonville, FL 32246
Questions?
Call 1-800-267-3156
FB GEN AGT 003 032017