Health First - Get Appointed


		855.443.4735 hfbroker@hf.org

Attention:

Thank you for your interest in becoming appointed with Health First Health Plans and AdventHealth Advantage Plans.

In order to complete the application process, please have the following documents available as they are required for upload:
	E&O
	Health License
	W9 for each entity in which you are paid

Documents needed if applicable:
	AHIP Certification (if selling Medicare)
	FFM Certification (if selling on the Marketplace)

Agent Information

*First Name

*Last Name

* indicates a required field

*Date of Birth

*Social Security Number

*Contact Role

*Email

*Cell Phone

*Florida Insurance Number

*NPN # (National Producers Number)

*License Effective Date

Home Address

*Home Street Address		Apt, Suite, Building, etc.
*Home City	*Home State/Province	*Home Zip/Postal Code

Mailing Address Same As Home Address

Mailing Address (Must Be Physical Address)

Mailing Street Address		Apt, Suite, Building, etc.
Mailing City	Mailing State/Province	Mailing Zip/Postal Code

Errors and Omissions

*Errors and Omissions Effective Date

*Errors and Omissions Expiration Date