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 317-232-3637 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.

*No person who has a conflict of interest with any activities of SHIP, whether personal, philosophical or financial, shall serve as a volunteer.