Priority Health Contracting

Priority Health Contracting Request

Michigan ONLY
New Agent ContractingExisting Agent Transfer
Thank you for your interest in being appointed with Priority Health. Please complete the following information to initiate the invitation to onboard.

Additionally, you will need to complete and upload the Priority Health Contracting paperwork and W9 that can be found at the following links:

Priority Health Change Form

https://360insurancegroup.com/wp-content/uploads/2021/07/fw9.pdf
New Agent Contracting

Thank you for your interest in being appointed with Priority Health. Please complete the following information to initiate the onboarding process.
Existing Agent Transfer

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

Existing Priority Health agents must complete and upload the Priority Health FMO Change Form and W9 that can be found at the following links:

https://360insurancegroup.com/wp-content/uploads/2021/07/NEW-GA-and-FMO-Change-Form-Priority-Health.pdf

https://360insurancegroup.com/wp-content/uploads/2021/07/fw9.pdf
Agent Name (As Listed On Your Insurance License)*

First NameMiddle NameLast NameSuffix
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Insurance License*

Cancelof
E&O Certificate*

Cancelof
Priority Health Contracting Paperwork*

Contracting Paperwork can be found at https://workdrive.zohoexternal.com/external/60031a77d5fa80c724bfbaa8c469a25ef5b13530da94ebfaec2f8300642a9a1d
Cancelof
FMO Change Form*

FMO Change Form can be found at https://360insurancegroup.com/wp-content/uploads/2021/07/NEW-GA-and-FMO-Change-Form-Priority-Health.pdf
Cancelof
W9*

W9 can be found at https://360insurancegroup.com/wp-content/uploads/2021/07/fw9.pdf
Cancelof
Sender Name
Sender Email
example@example.com
Should be Empty:

Priority Health Contracting Request