Appointment Information

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 Resident Producer’s License.
  • Electronic copy of your current Errors and Omissions Certificate.
  • Electronic copy of a current, completed and signed W-9.
Producer Name (exactly how it appears on license)
Producer License Information
MM/DD/YYYY
Producer Contact Information
Agency & Commission Information

Commission payments will be deposited into the account you provide below

Where is my routing number?
Where is my account number?
Upload the following files:
Download a W-9 (PDF form)
Please certify that you:
Please verify that you have read and agree to the following: