Medicare Contracting Request
Do you currently hold a health license in one of the following states: FL, AL, AZ, CO, GA, TN, or TX ?
Yes
No
Where is your resident state?
Florida
Alabama
Arizona
Colorado
Georgia
Tennessee
Texas
Do you have Errors and Omissions Insurance (E&O)?
*
Yes
No
I understand that if I do not have E&O, I will receive an email with links for potential E&O providers. Once I get E&O ($1 million minimum coverage), I will reapply.
Yes
Have you completed AHIP training for 2023?
*
Yes
No
If you have not completed AHIP training, please be aware that the cost is approximately $125.
*
I confirm that I understand that there is a cost for AHIP training
Agent Name
*
First Name
Last Name
EF Number (if you are affiliated with Equis)
NPN (National Producer Number)
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Social Security Number
*
Birthdate
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Recruiter Manager
*
Please Select
Jerrod Ewing
Eric Boling
James Glascott
Rick Hazouri
Charles Knox
David Schneider
Darren Willis
Regional Email
example@example.com
Other
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