CHRISTUS HEALTH CONTRACT REQUEST
Contract for 2019
Check Christus Health and Request Additional Carriers:
Christus Health
Other
Request Short-Term Carriers? Short-Term Coverage now approved for 364 days of coverage:
National General
UnitedHealthcare
Dental Carrier
Spirit 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: