Get Appointed with Allied National Carriers

Read and/or Print These Instructions ​Before Using the Forms.

The Allied National appointment system is easy! Simply fill out the appointment forms, print, and then mail, fax or e-mail your completed forms.

To Complete Your Appointment, Please Follow These Steps:

1. From the list of links below, select a form and click on the link to view the pdf.
2. When you have completed all of the required information, review for accuracy.
3. Print the completed form and sign on the signature line.
4. Return the completed form to one of the following:
   1. E-mail:  [email protected]
   2. Fax:  (913) 945-4397
   3. Mail:  Licensing
                Allied National
                P.O. Box 29187
                Shawnee Mission, KS 66201-9187

Please Note: If this is your first carrier appointment with Allied, you must fill out the Allied commission agreement and W9 forms to authorize commission payment. You must also submit photocopies of your current state license by e-mail, fax or mail to the addresses above.

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Carrier Appointment & Compensation Forms

Health Products

• Allied Agent of Record Appointment Form
• Companion Life Appointment Form (Pivot Health Short Term Medical)​
• Crum & Forster Appointment Form (using North River Insurance Company) (Pivot Health Short Term Medical)
• Pan-American Life Insurance Company Appointment Form (Pivot Health Short Term Medical) ​
• Pan-American Life Insurance Company Background Authorization (Pivot Health Short Term Medical) ​
• Renaissance Dental & Vision (Pivot Health Brilliant™ Dental)
• Fidelity Security Life Insurance Company® (FSL) Appointment Form (Funding Advantage Stop Loss and Dental Design) - FSL uses an online appointment process. Please contact Allied Sales for details when you wish to become appointed by emailing [email protected].

Compensation Forms

• IRS W9 (required for first carrier appointment) - Required for first carrier appointment.

• Allied Compensation Agreement and Direct Deposit Authorization Form (required for first carrier appointment) - Required for first carrier appointment.

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Looking for Something Different?

Download brochures, applications, and other resources for all Allied plans. Use these materials to present plan options to your clients.