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 / Province

Postal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.
Agent NPN #
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.
Form Completed By

First NameLast Name
Signature
Should be Empty: