HEALTHCARE PLAN(S) CONTRACT REQUEST FL
Send Contract for SHORT-TERM CARRIER(S) in my state:
National General (12 X 2 Coverage Option)
UnitedHealthOne (Up to 36 Months of Coverage)
Pivot Health (New Bridge to Medicare)
HII
Philadelphia American (Scheduled Benefit Plans)
Alternative Health Plan (Permanent HEALTH SHARING PLANS for every need and budget):
Aliera Healthcare
Also send Contracting Information for SPIRIT DENTAL AND VISION:
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 with additional information: 901-221-8834
Should be Empty: