Agent Sign Up

General Information line
Agent Type
First Name
required
Last Name
required
Gender
required
Email
required
Phone
X required
Secondary
X
Address 1
required
Address 2
City
required
State
required
Zip Code
required
Date Of Birth
RadDatePicker
Open the calendar popup.
required
SSN
required
Licensed States required
StateExpiry DateLicense File Name   
There are currently no Agent State Licenses listed.
Required fields are indicated
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Contracting Process
Once you complete your account registration, and your licenses are verified, you will immediately be able to offer SureMed to your clients.
Commissions
Agents are paid great commissions on SureMed. For actual compensation, please contact us.
Marketing
Once contracted, you will receive your own customized agent website allowing you to easily market SureMed to your clients.