Agent Prospect Form

You must be licensed with the NC DOI to become a Blue Cross NC appointed agent. If interested in Under 65 Individual market, you must also be CMS certified.

Select the market segment you are inquiring about

FTE Selection *

Are you interested in referring this group to Blue Cross NC for a proposal from our Direct Sales Team? *
Yes
No
**We are not appointing new agents in the 1-50 group segment at this time.

Is your group a current Blue Cross NC Customer? *
Yes
No

We are not appointing new agents for existing Blue Cross NC Groups.

If your group is currently with Blue Cross NC, please do not complete this form. In the meantime, learn more about our business offerings or return to our Agents page.

We are not appointing new agents for existing Blue Cross NC Groups.

If your group is currently with Blue Cross NC, please do not complete this form. In the meantime, learn more about our business offerings or return to our Agents page.

Group Information

Group Name *
Group County *

Group Contact Information

First Name *
Last Name *
E-mail *
Phone *

Is your group a current Blue Cross NC Customer? *
Yes
No

Group Information

Group Name *
Group County *

Agent Information

First Name *
Last Name *
Agency Name *
E-mail *
Phone *
Tell us more why you would like to be appointed with Blue Cross NC?* *

We are not appointing new agents for existing Blue Cross NC Groups.

If your group is currently with Blue Cross NC, please do not complete this form. In the meantime, learn more about our business offerings or return to our Agents page.

Agent Information

First Name *
Last Name *
Agency Name *
City *
State *
Zip Code *
County *
E-mail *
Phone *
Tell us more why you would like to be appointed with Blue Cross NC?* *

Leave this field blank