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
Producer Contact Information
Agency & Commission Information
Upload the following files:
Please verify that you have read and agree to the following: