CARRIER CONTRACT REQUEST
Get Contracted NOW for 2018
Check the ACA Health Carriers that are in your state that you would like to be appointed with:
Molina (TX, FL, MI, NM, OH, and WA)
BCBS (TX, NM, OK and IL)
Medica (IA, KS, ND, NE and WI)
Health Net (CA and AZ)
Bright Health (CO and AL in Shelby and Jefferson Counties)
Ambetter ((Closed in Texas), AR, AZ, CA, IL, IN, KS, MS, MO, NV, NH, OH and WA)
Other
Are you in need of Short Term Medical Carriers?
National General
United Healthcare
ACA Alternative Carrier
Aliera Healthcare
Dental Carrier (22.5% Level Commission)
Bright Dental
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
Please Select
Social Security Number
Federal Tax ID
License Information
NPN Number
*
123456789
State(s) to be appointed in
List States
Submit Request
Broker Contracting, Kim Eagle, Phone: (817) 312-3008, Email:
keagle@mycoreinsurance.com
Should be Empty: