HSA Business Partner Signup

Business Partner Type
First Name
Last Name
Business Name
Street Address 1
Street Address 2
City
State
Zip Code
Preferred Method of Communication
Email Address
Work Phone Number	Ext
Mobile Phone Number

Are you the only producer or will there be multiple producers?

How many producers will you be signing up with us?

What is the name of the agency?

My agency was not found:

What is the name of the agency?
What is the street address of the agency?
Street address 2
What is the city of the agency?
What is the state of the agency?
What is the zip code of the agency?
What is the phone number for the agency?	Ext

Average group size in your target market

If you have a website, please provide the web address:

What is the name of your broker/dealer?

If you use a GA or MGA, who are they?

Other (if you use more than one):

Specify a logon user ID to be used for accessing the business partner portal
How did you hear about us?
Who?
Which one of our sales people did you speak to?
Is there anything you need immediate assistance with?

Agent: A benefit/insurance advisor that represents only a single carrier or company. (Captive)
Broker: A benefit/insurance advisor that contracts with multiple carriers or companies. (Independent)
Carrier Representative: An employee carrier field representative.
Consultant: Consultant - A benefit/insurance advisor that only works on a fee basis for their clients.
GA/MGA: A wholesaler of products/services for brokers/agents/agencies.

The primary address you entered was:

USPS recommended address is:

Use the address entered. Use USPS recommendation. Make changes and revalidate.

The agency address you entered was:

USPS recommended address is:

Use the address entered. Use USPS recommendation. Make changes and revalidate.

The commission address you entered was:

USPS recommended address is:

Use the address entered. Use USPS recommendation. Make changes and revalidate.

You have chosen to sign up as a [BusinessPartnerType]. To properly configure this type of business partner, we request that you call our team of dedicated professionals to answer a few questions and set you up correctly. You can call us toll free at 888-677-1115; we are available Monday through Friday, from 8 a.m. – 4:30 p.m. Central Time. Thank you for your interest in doing business with UMB Bank.