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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:  underwriting@alliednational.com
    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.

Carrier Appointment & Compensation Forms

Health Products
  • Allied Agent of Record Appointment Form
  • Companion Life Appointment Form (Pivot Health Short Term Medical)
  • Standard Life and Accident Insurance Company Appointment Form (Pivot Anchor)
  • Crum & Forster Appointment Form (using North River Insurance Company) (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 sales@alliednational.com.
Compensation Forms
  • IRS W9 (required for first carrier appointment) - Required for first carrier appointment.
  • Allied Compensation Agreement (required for first carrier appointment) - Required for first carrier appointment.
  • Agent Schedule of Compensation
  • Direct Deposit Authorization Form

Looking for Something Different?

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

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  • Home
  • Employers
    • Self-Service Login
    • Prescription Benefits
    • Lab Program
    • Abenity Discounts
    • Employer Resources >
      • Freedom Hybrid - Employer Resources
      • HSA Freedom Hybrid - Employer Resources
      • Freedom Traditional - Employer Resources
      • Cost Saver Plan - Employer Resources
      • PPO - Employer Resources
      • Freedom Essentials - Employer Resources
      • MEC - Employer Resources
      • Apex MEC - Employer Resources
      • Community Health Plan - Employer Resources
      • Prime-Fundamental Care - Employer Resources
      • Vault PPO - Employer Resources
      • Vault RBP - Employer Resources
    • EBA Newsletter
  • Members
    • Member Resources
    • HealthCare Assistant
    • HealthChoices
    • Self-Service Login
    • Find A Provider
    • Prescription Benefits
    • Telehealth
    • Lab Program
    • Abenity Discounts
    • Member Download Forms >
      • Appeals
    • Member FAQs
  • Agents
    • Agent Edge
    • Plans >
      • Level Funding >
        • Freedom Plan >
          • Hybrid
          • Traditional
          • Essentials
        • PPO
        • Cost Saver Plan
        • Preventive Minimum Essential Coverage
        • Direct Primary Care >
          • DPC Directory
      • Dental Design
      • Pivot Health Individual Plans >
        • Short Term Medical
        • Fixed Benefit
        • Brilliant Dental
      • Premium Only Plan
    • Self-Service Login
    • Download Forms - Agents
    • Product Availability
    • Training Webinars
    • Agent FAQs
  • Provider
    • Provider Verification
    • DPC & Benefit Plans
  • About Us
    • History
    • Testimonials
    • Blog
    • Newsroom >
      • Allied Logos
  • Contact Us