HEALTH CARRIER CONTRACT REQUEST FOR KANSAS
Get Contracted NOW for 2018
Check the ACA Health Carrier that you would like to be appointed with:
Medica
Ambetter
Are you in need of Short Term Medical Carriers?
National General
United Healthcare
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
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, Tom Weis, Phone: (901) 221-8834, Email:
tweis@mycoreinsurance.com
Should be Empty: