HealthChoice of Michigan Insurance Agent Identification Form
Group Name
*
Please enter the name of your business here.
Group Number
Please enter your Group Number here.
Employer Group Contact Person
*
Your First Name
Your Last Name
Contact Email
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you working with an agent related to the HealthChoice of Michigan benefits?
Yes
No
Insurance Agent Name
First Name
Last Name
Insurance Agency Name (if applicable)
Submit
Should be Empty: