MEDICA CONTRACT REQUEST
Get Contracted NOW for 2019
Check the ACA Health Carrier that you would like to be appointed with:
Medica
Are you in need of Short Term Medical Carriers?
National General
ACA Alternative Carrier:
Aliera Healthcare
Name
*
First Name
Middle Name
Last Name
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Phone
*
-
Area Code
Phone Number
Alt Phone
-
Area Code
Phone Number
Fax Number
-
Area Code
Phone Number
E-mail Address
*
youremail@youremail.com
Tax ID Number
Federal Tax ID
*
Federal ID: 38-2345676 or Social Security 345-45-4545
Tax ID Type
*
Social Security Number
Federal Tax ID
License Information
NPN Number
*
123456789
State(s) to be appointed in
List States: OH, IN, ....ETC
Submit Request
Broker Contracting, Kim Eagle, Phone: (817) 312-3008, Email:
keagle@mycoreinsurance.com
Should be Empty: