HAP (Health Alliance Plan) Contracting Request - MICHIGAN ONLY

Thank you for your interest in being appointed with HAP.  Please complete the following information to initiate the invitation to onboard.

This same form is used for "new to contract" or "GA/FMO Change Request" contracting.

Additionally, if you are new to contract the on-boarding link gives you the option to contract as an AGENCY or as an AGENT. (If selecting Agency, then, once appointed, invitations can be sent to agents that you desire to be under your agency).

This agreement needs to be signed by the commission-receiving entity. If an Agency is receiving commission, the Agency name and Principal of the Agency need to acknowledge this agreement. If an agent is receiving the commission, the agent needs to acknowledge this agreement. This agreement must also be signed by the Field Marketing Organization. Agreements take effect on date signed and administration fee will be paid on business written after date signed.

I understand that I am completing Exhibit E for HAP Contracting and have been provided access to review this exhibit before making my contracting submission.

By selecting the "SUBMIT" button, I understand that I will not only receive a copy of my submission to the address I have listed above, but my submission will also be sent, on my behalf, to initiate my contract for processing.