Agency Appointment

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

Agency Information

Name of agency *

Tax ID *

Address 1 *

Address 2

City *

State *

Zip *

Agency Bank Account Information

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

Agency Routing Number * Where is my routing number?

The above routing number is for:

Agency Account Number * Where is my account number?

Upload the following files (PDF files only)

Current Errors & Ommisions Certificate * Only PDF files are allowed to be uploaded.

Current Completed and Signed W-9 * Only PDF files are allowed to be uploaded. Download a W-9 (PDF form)

Person submitting this form

First Name *

Middle Name

Last Name *

Email Address *

Phone Number *

Please certify that agency:

Have not been charged with or convicted of committing any criminal offense.

Do not have any charges for violating any criminal law(s) pending.

Are not currently prohibited by any state from involvement in the sale of insurance products.

Have not received notice that a state proposes to prohibit you from involvement in the sale of insurance products.

Are not the subject of, or otherwise part of, any ongoing federal or state investigation.

Please verify that agency have read and agree to the following:

I have read and agree to the EMI Health Producer Agreement (PDF).

I have read and agree to the EMI Health Business Associates Agreement (PDF).