IN.gov - Skip Navigation

Note: This message is displayed if (1) your browser is not standards-compliant or (2) you have you disabled CSS. Read our Policies for more information.

Indiana Department of Insurance

SHIP New Counselor Application SHIP New Counselor Application

Important Notes: This application will not be fully processed until you have called the State SHIP office to provide your Social Security number and Date of Birth to consent to a Criminal History Check. Once you have finished this application, you will need to contact  Elizabeth Hewitt, SHIP Office Manager, within 48 hours at (800) 452-4800, ext. 223 during business hours to finalize this process.

By submitting this application, I am agreeing to the following SHIP Non-Conflict of Interest policy, which will also be provided during your initial training for your reference.

The State Health Insurance Assistance Program (SHIP) requires that counselors shall not promote private or personal interest in conjunction with the performance of duties covered in State Health Insurance Assistance Program guidelines. To comply with these requirements, I agree to the following:

I will in no way attempt to conduct market research, nor solicit or persuade clients to purchase a specific type of medical insurance coverage, to convert an existing insurance policy to another carrier, to go to a specific provider of service for treatment, or to direct a client to a specific agent or a specific profit-based billing service.

I will not disclose or use confidential information obtained as a result of my association with or access to any client for personal gain, advantage for my employer, any other parties, or for any other purpose not directly required by this insurance counseling program.

I hereby acknowledge my obligation to respect the confidentiality of the client and to exercise good faith and integrity in all dealings with the client in the performance of my duties as a counselor for the State Health Insurance Assistance Program (SHIP). I also understand that a breach of this agreement will result in my immediate dismissal from my counselor duties and may subject me to liability for breaching the client’s right to privacy and confidentiality. Further, I agree to defend and indemnify the Sponsoring Organization, the Department of Insurance, the Family and Social Services Administration, the State of Indiana, and SHIP from any costs, expenses, damages and claims arising from any act or omission I perform under SHIP that is not performed in good faith, including but not limited to any act constituting a breach of this agreement or any program guideline.

Applicant Information
Name (First/Last):


Gender:
Male | Female

Other Names Used (maiden name):


Phone:
( -

Secondary Phone:
( -

Ethnicity/Race:


Email:


Disabled?:
Yes | No

Home Address

Address:


County:


City:


State:


Zip:


Mailing Address if different than home address

Address:


County:


City:


State:


Zip:


When applicable, do you prefer information by:
Mail | Email

Do you prefer to receive SHIP mail:
at home | at SHIP site

Detail Information
How did you hear about volunteering for SHIP?:


Past/current occupation (if retired, please state here):


Are you a paid employee of your sponsoring organization?
Yes | No

Are you currently participating in other volunteer programs?
Yes | No

Past volunteer experience:


Do you fluently speak another language other than English?
Yes | No

Languages:


Fluency:


Please list any special skills that may benefit our organization:


What are your reasons for wanting to counsel for SHIP?


Please mark the days and times you are available to counsel:
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Sun.

Any counseling hours past 5 p.m. are for volunteering at site only. Most SHIP counseling requires availability during regular business hours.

There are several ways you can spend your counseling time with SHIP. Please let us know how you would like to help by checking your preferences below (choose as many as you would like):
Site Counselor Answers local calls, 800 calls transferred to the site, and assists clients in person.
Phone Counselor Answers local calls and calls transferred from the State office to home or site (your choice).
Special Events/Presentations Educates at presentations, health fairs etc.

References
1.
Name:


Address:


City:


State:


Zip:


Phone:
( -

2.
Name:


Address:


City:


State:


Zip:


Phone:
( -
Counselor Agreement

SHIP depends on grant funding to provide free services to Indiana Medicare beneficiaries, so we do ask for a certain level of commitment from our counselors.

As a SHIP counselor, you understand:

  • that you will be providing one-on-one health insurance counseling at a counseling site or by telephone.
  • that you will need to make appropriate referrals when necessary.
  • that you should read materials sent to you, keep your manual updated, and attend further trainings.

The following are on-going requirements we ask of all SHIP counselors. If these basic requirements haven’t been met, SHIP reserves the right to end any volunteer position; however, we will always do everything we can to accommodate ALL of our participating counselors. If at any time during your time with us you feel you cannot complete these requirements, please speak with your Area Manager to make other arrangements.

  • I agree to volunteer for a minimum of one year.
  • I agree to complete the initial 5-day training (a total of 30 hours).
  • I understand that I cannot be affiliated with any insurance company or insurance claims filing business to the extent that it could be used for personal and/or financial gain during my time as a SHIP counselor.
  • I will keep all client information confidential and never recommend a specific insurance policy, company or agent.
  • I agree to complete at least nine client contacts forms per month complete the appropriate forms required by the National Public Reporting (NPR) System.
  • I agree to attend bi-annual update training. If I will be unavailable for update training, I will make prior arrangements with my Area Manager.

By clicking SUBMIT, you are agreeing to the above Counselor Agreement statements as well as consenting to a Criminal History check.