SHORT-TERM PLAN(S) CONTRACT REQUEST
Send Contract for SHORT-TERM CARRIER(S) in my state:
UnitedHealthOne
National General
Alternative Health Plan (Permanent Health Plans for Budget Minded Clients):
Philadelphia American (Scheduled Benefit Plans)
Also send Contracting for SPIRIT DENTAL AND VISION (The Easy To Sell Dental):
Spirit Dental and Vision
Full Name as appears on your License
*
First Name
Middle Name
Last Name
Contract Information
E-mail
*
name@youremail.com
Phone Number
*
-
Area Code
Phone Number
License Information
NPN Number
1234567
State of Resident License
List State of Resident License
SUBMIT CARRIER CONTRACT REQUEST(S)
Contact Core Benefits Group for additional information: 603-329-6197
Should be Empty: