SBHIS Agent Application

Full Name *

Phone Number *

Email Address *

Do you currently hold an active insurance license? *

Yes No

Do you have an AHIP Certification? *

Yes No

Do you have E&O Coverage? *

Yes No

Are you interested in selling all health plans? *

Yes No

Select the plans you are interested in selling:

HMO-SNP MAPD MedSup PPO PDP PACE

What is the main ZIP code of the area you would like to sell in? *

Languages Spoken *

Separate multiple languages with commas

Do you have Medicare experience? *

Yes No

Years of Experience in Insurance

How did you hear about our agency?

Become an SBHIS Agent