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Search for:
Medicare
Medicare Supplement
Medicare Advantage (Part C)
Prescription Drug Plans
Medicare FAQ
Individual & Family
Affordable Care Act (ACA)
Affordable Care Act (ACA) FAQ
Dental/Vision Plans
Small Business
Additional Coverage
Hospital Indemnity
Cancer Policies
Critical Care
Life Insurance
Final Expenses
Find an agent
Events
About Us
Contact
Staff
Agent Resources
Become An Agent
ePH Cares
Medicare
Medicare Supplement
Medicare Advantage (Part C)
Prescription Drug Plans
Medicare FAQ
Individual & Family
Affordable Care Act (ACA)
Affordable Care Act (ACA) FAQ
Dental/Vision Plans
Small Business
Additional Coverage
Hospital Indemnity
Cancer Policies
Critical Care
Life Insurance
Final Expenses
Find an agent
Events
About Us
Contact
Staff
Agent Resources
Become An Agent
ePH Cares
New Agent Intake Form
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New Agent Intake Form
New Agent Intake Form
eplatinum
2022-05-05T12:09:41-05:00
I am (Please Check)
*
Independent Agent
Subagent w/an Agency
Which Agency?
*
First & Last Name
*
Home Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Agent Business Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
(if different from home)
Agent Gender
*
Select...
Male
Female
NPN #
Home Phone
*
Cell Phone
Business Fax
How would you like to identify?
*
As an EPH Agent
As my own agency but "Powered by EPH"
As an Individual/ACA Agent
Do you want to request an EPH Email?
*
Yes
No
NOTE:
must utlilize EPH to have a website and/or business cards
Email will read as:
*
(firstinitial last name)@myeph.com
Please select from the following if you WANT TO CONTRACT:
ABCBS
Aetna Coventry
Aetna MAPD/PDP
Aetna Supp.
Aliera
All Well/Centene
Ameritas
Arise
Aspirus
Children's Community Health Plan
Cigna
Common Ground
Dean
Gerber
GTL
HealthSapiens
Humana
iCare
Manhattan Life Med Supp.
Medico
Medi-Share
Molina
MOO
Network Health
OTHER
Peterson International
Pivot
Security Health
Security Health Plan Med Supp.
Silver Script
United HealthCare
United of Omaha Final Expense
Unity/Quartz
WPS
If other, please list here:
Please select from the following if you are ALREADY CONTRACTED:
ABCBS
Aetna Coventry
Aetna MAPD/PDP
Aetna Supp.
Aliera
All Well/Centene
Ameritas
Arise
Aspirus
Children's Community Health Plan
Cigna
Common Ground
Dean
Gerber
GTL
HealthSapiens
Humana
iCare
Manhattan Life Med Supp.
Medico
Medi-Share
Molina
MOO
Network Health
OTHER
Peterson International
Pivot
Security Health
Security Health Plan Med Supp.
Silver Script
United HealthCare
United of Omaha Final Expense
Unity/Quartz
WPS
If other, please list here:
State license(s)
Max. file size: 50 MB.
Your Individual and/or agency license for any states you will be selling in.
E&O Insurance
Drop files here or
Select files
Max. file size: 50 MB.
Please provide your current E&O certificate
Professional photo
Accepted file types: jpg, png, Max. file size: 50 MB.
500x700px please
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