Broker and Agency Appointment

Home Search

Add Agency

Agency Appointment

This is a two-step process:

  1. Add an agency, by filling out the form below.
  2. Add broker(s) to the agency, by filling out the subsequent page(s).

In order to become appointed with EMI Health please complete the form below. You will need to submit the following during this process:

  • Electronic copy of your current agency Errors and Omissions Certificate.
  • Electronic copy of a current, completed and signed agency W-9 (PDF Form)
Step 1/2: Add agency
Please correct the following errors:

Agency Information

Formats: XX-XXXXXXX or XXXXXXXXX

Agency License Information

MM/DD/YYYY

Agency Bank Account Information

All commission payments will be deposited into the agency account provided.

Where is my routing number?
Financial Institution not found. Verify the routing number above is correct.

Where is my account number?

Upload the following files (PDF files only)

Drag and Drop License Here
file icon
Only PDF documents are allowed to be uploaded.
Drag and Drop Certificate Here
file icon
Only PDF documents are allowed to be uploaded.
Drag and Drop W9 document Here
file icon
Only PDF documents are allowed to be uploaded.

Person submitting this form

Please certify that agency:

Agree to the following: