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USFSB Representative Fact Sheet
Fill out the form below and a staff member will contact you as soon as possible.
Company:
Representative Name:
Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Phone:
Fax:
Email:
If this is a P.O. Box, please provide your street address as well.
Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Business Structure
Corporation
Partnership
Sole Proprietor
If fees are to be paid to the business, Tax ID #
SSN
Licensed States
Lines of Insurance
Insurance Companies you currently work with
Do you have clients who work internationally?
Choose...
Yes
No
Questions/Comments:
Broker Rules and Procedures:
In addition to the health insurance plans offered to Brokers on the USFSB website, there are many other plans offered through Joseph R. Cardamone, Independent Insurance Agent, which are listed on the main Insurance Clearinghouse section of www.USFSB.com and also listed on www.josephrcardamoneagency.com. All commissions and fees are as stated on the Broker Commission Schedules in the Broker Section of www.USFSB.com. Brokers can only receive commissions and fees from sales made in states in which they are duly licensed. All Commissions and Fees as stated are based on the current commission rates or premiums of the carriers and are subject to change without notice. USFSB and Joseph R. Cardamone Agency provides a Rep Report and commission payment on or about the 10th day of each month for the prior month's business based on the commissions and/or fees actually received by USFSB or Joseph R. Cardamone Agency. If the accumulated commission is less than $100, payment is not made until you have reached $100 or more in commissions. On December 10th of each year, all unpaid commissions will be paid regardless of accrued total. In some cases, a Company Census is required to determine plan availability and monthly premium rates. In those cases, the Broker must first submit a complete and accurate Company Census before any quotes can be obtained from the carrier. All insurance applications must be submitted in an acceptable manner. All insurance applications, in order to be deemed acceptable, must be timely, ,complete and contain all information and back-up documentation required by the applicable carrier as well as be accompanied by all required premiums, fees and dues. Coommssions and fees paid to Brokers based on Commissions and Fees which are returned by USFSB and/or Joseph R. Cardamone Agency, for any reason, shall be deducted from future payments to the Broker. If any insurance or membership is terminated, for any reason, and then subsequently re-enrolled, Broker shall not be entitled to any further compensation on that business unless said re-enrollment is due to the efforts of the Broker. Brokers shall receive no compensation other than those stated on the Broker Commission Schedules in the Broker Section of www.USFSB.com.
View Rules and Procedures in PDF Format for Printing
I agree to the above rules and procedures.
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