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:

  • Electronic copy of your current agency Errors and Omissions Certificate.
  • Electronic copy of a current, completed and signed agency W-9.
Agency Information
Agency Bank Account Information

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

Where is my routing number?
The above routing number is for:
Where is my account number?
Upload the following files (PDF files only)
Only PDF files are allowed to be uploaded.
Only PDF files are allowed to be uploaded. Download a W-9 (PDF form)
Person submitting this form
Please certify that Agency:
Please verify that Agency have read and agree to the following: