New Agent Intake Form - EPlatinum Health Insurance Agency

I am (Please Check)*

Which Agency?*

First & Last Name*

Home Address*

Street Address City State ZIP Code

Agent Business Address

Street Address City State ZIP Code

(if different from home)

Agent Gender*

NPN #

Home Phone*

Cell Phone

Business Fax

How would you like to identify?*

Do you want to request an EPH Email?*

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:

If other, please list here:

Please select from the following if you are ALREADY CONTRACTED:

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

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