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.

Step One: Add agency

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: