ALH NETWORK | CONTRACTING

ALH NETWORK | Medicare Contract Request

First Name *

(as appears on license)

Last Name *

(as appears on license)

Email *

Agent Email Address

Phone *

Agent Phone

Agent DOB *

Agent SSN *

Agent NPN *

Residential Address *

Complete Residential Address

Agency Name (if applicable)

Agency NPN (If applicable)

Agency Tax ID (If applicable)

Do you need a release?

YES

NO

If "YES" you must have a release from you current Upline. If you already have one please upload here:

🚨🚨🚨 If you Require a release additional information may be required by the carrier. You can download the form after submitting.

States You are requesting *

(Type in the abbreviation and separated by comma or a space)

UHC is the only Medicare Advantage company that doesn't pay the agents' state appointment fees. Agents pay the state fees directly out of their commissions. Each state you are applying for has a different fee. If you would like to be contracted in fewer states with UHC, please let us know in the space above.

By submitting this form, you acknowledge and agree to UnitedHealthcare's contracting fees. You can find the UHC FEES HERE

ALH NETWORK | Medicare Contract Request

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