Health First

Get Appointed!

Thank you for your interest in becoming appointed with Health First Health Plans and Florida Hospital Care Advantage.

To become appointed:
Enter all information
Upload required documents
Click on 'Submit to Health Plans'

You will be contacted when your appointment has been processed.

= Required Information

Agent Information

*Title
*First Name		*Last Name
*Date of Birth	[ 4/21/2018 ]	*Social Security Number
*Cell Phone		*Email
*Florida Insurance Number		*NPN # (National Producers Number)
Commissions Paid To		*Commissions Mailed To

Lines of Business Sold

*Group		*Individual
Medicare		Selling on the Individual or Shop Marketplace

Health Plans Sales Executive

Are you currently working with a Health Plans Sales Executive?

Home Address Information

*Home Street Address
*Home City
*Home State
*Home Zip
*County

Agency Information

Check here if you are not affiliated with any agency

*Agency Name
*Agency Main Phone
*Federal Tax ID

Agency Address Information

Home address is the same as agency address
*Agency Street Address
*Agency City
*Agency State
*Agency Zip

Required Documents

Click on each required document, review information, save and print a copy for your personal records. You will be asked to electronically sign the documents under the 'Acknowledgment Statement'.
Agent and Broker Agreement Business Associate Agreement
You are required to submit a signed W-9 to complete your appointment process, you can use th W9 template below or upload your own W9. Follow these steps to ensure proper processing of your appointment:
IRS Form W-9
1. Open the form above labeled IRS Form W-9.
2. Fill out the fillable PDF in its entirety.
3. Save the PDF for your personal records.
4. Sign the PDF using an E-Signature or print the form off, sign it and scan the signed form to your computer.
5. Upload the signed PDF in the below section.

Upload Required Documents

Signed W-9:
Proof of License:
Proof of Errors and Omissions (E&O) Coverage:
Copy of Current AHIP Certification:

Acknowledgement Statement


By checking the box and entering my name below, I am indicating my intent to electronically sign each of the listed documents. I acknowledge that I have been provided the required appointment documents, and that I have read and agree to be bound by the terms and conditions of the documents listed below. I warrant that all of the information that I have provided is true, complete, and accurate.

Business Associate Agreement
Agent and Broker Agreement

I agree that my electronic signature is the legal equivalent of my manual signature on this Agreement, and I agree that no third-party verification is necessary to validate my electronic signature.
*Full Name