UA General Agency

Take the next step.

Seize the opportunity for growth and unlimited success by completing the form below. After you're finished, you'll be able to print your contracting forms immediately. If you have any questions, contact Agency Services at 1-800-925-7355 or email us.

* = Required fields.

Personal Information

*FIRST Name (as licensed): Middle Initial:
*LAST Name:
Social Security Number: - -
*Address:
*City:
*State:
*Zip:

Contact Information

*Work Phone Number: () -
Cell Phone Number: () -
*Home Phone Number: () -
*Email Address:
Best time to contact?

Sales Experience

*Are you:

a Marketing Organization or an Agency?
producing for a Marketing Organization or an Agency?
producing individually?

How many active agents?
How many producing agents?

General Agency Name:

*Your Primary Market(s):

  Health
  Life
  Senior (Age 65+)
  Other:

What is your production?

Last year's annualized health premium: $
Last year's annualized life premium: $

*How long have you
sold insurance?

Submit your information to start your relationship with United American and
access your contracting paperwork.