DEPARTMENT OF INSURANCE

DEPARTMENT OF INSURANCE

Affiliations

Name	Fortin, William	DOIID	701128	NAIC NPN	2431993

License - Line of Authority Information

Status	Residency	Class	Line of Authority	Active Date	Inactive Date	License Expiration Date
Active	Non Resident	Agent	Health	3/16/2009		12/31/2024
Active	Non Resident	Agent	Life	3/16/2009		12/31/2024
Active	Non Resident	Life & Health Consultant	Not Applicable	3/30/2012		12/31/2024
* If a status Is Pending, Pending Replacement,Or the record displays Affidavit On File, click On them For more details.

License Renewal Information

Class	Invoice Date	Response Due / Expiration Date	Response Received Date	Payment Received Date	Renewal Complete
Agent	10/15/2024	12/31/2024
Life & Health Consultant	10/15/2024	12/31/2024

Appointments with the following Insurers

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Active	Anthem Health Plans of Kentucky, Inc.	300999	Agent - Health	3/8/2020
Active	CIGNA Dental Health of Kentucky, Inc.	300904	Agent - Health	1/5/2015
Active	CIGNA Health & Life Insurance Company	301783	Agent - Health	12/4/2014
Active	CIGNA Health & Life Insurance Company	301783	Agent - Life	12/4/2014
Active	Hartford Life and Accident Insurance Company	300878	Agent - Health	5/27/2015
Active	Hartford Life and Accident Insurance Company	300878	Agent - Life	5/27/2015
Active	Provident Life and Accident Insurance Company	301525	Agent - Health	12/20/2023
Active	Provident Life and Accident Insurance Company	301525	Agent - Life	12/20/2023
Active	Starmount Life Insurance Company	628031	Agent - Health	12/20/2023
Active	UNUM Life Insurance Company of America	300817	Agent - Health	12/20/2023
Active	UNUM Life Insurance Company of America	300817	Agent - Life	12/20/2023
Active	UnitedHealthcare Insurance Company	300946	Agent - Health	6/10/2010
Active	UnitedHealthcare Insurance Company	300946	Agent - Life	6/10/2010
Inactive	UnitedHealthcare of Kentucky, Ltd.	301337	Agent - Health	6/10/2010	12/1/2016
Inactive	UnitedHealthcare of Ohio, Inc.	300493	Agent - Health	6/10/2010	12/1/2016
Active	Unum Insurance Company	301499	Agent - Health	12/20/2023
Active	Unum Insurance Company	301499	Agent - Life	12/20/2023
Active	Vision Service Plan Insurance Company	300526	Agent - Health	10/5/2022

Designated to act on behalf of the following Business Entities

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Active	Designated Agent Company Inc.	681257	Agent - Health	3/10/2020
Active	Designated Agent Company Inc.	681257	Agent - Life	3/10/2020
Active	Mercer Health & Benefits LLC	607080	Agent - Health	4/5/2012
Active	Mercer Health & Benefits LLC	607080	Agent - Life	4/5/2012
Active	Mercer Health & Benefits LLC	607080	Life & Health Consultant - Not Applicable	4/5/2012