Equis Financial Health Carrier Contract Request Form

Health Carrier Contract Request Form

Please complete all required fields. Please note that this is a request for a carrier contract to be emailed to you from the carrier portal.
First Name
Last Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth

MonthDayYear
Date
Gender
Email Address
example@example.com
Business Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell/Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Agent NPN #
Agent SSN
Regional Manager/Base Shop
Check the Product Availability page first to make sure the carrier is available in your state(s).
MA: Medicare Advantage and Medicare Advantage Prescription Drug Plans - AHIP Required

MS: Medicare Supplement

Ancillary: Dental, Vision, Hearing, Critical Illness, Hospital Indemnity.
Please select the carrier(s) you want to contract with:
* At this time, Humana is only accepting:
- Hierarchy transfers (requires a completed Agent Assignment Form and a release from the top of the current hierarchy), or
- Brand-new agents who have never been contracted with Humana.
No previously termed agents may onboard at this time, including agents termed due to LOP (Loss of Production).
*Please initial below confirming you have read the Humana contracting eligibility requirements.
States You Are Health Licensed In (Select All That Apply):
Please download the following forms, complete, and attach the completed PDFs using the upload fields below.
Agreement
Agreenent File Upload

Cancelof
EFT File Upload

Cancelof
W9 File Upload

Cancelof
Form Completed By

First NameLast Name
Signature
Should be Empty: