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Alignment Health Plan

Agents only. Does not contract agencies.
Please download the Direct Deposit Agreement Form, complete it, and upload it at the bottom of this page to be submitted with the rest of your information. You commissions will be deposited directly from Plan Advisors the account provided.
Please complete the form and click Submit to request contracting.

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Carrier
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Upline GA
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Upline MGA
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Upline FMO
Currently contracted?*
Are you currently contracted with Alignment Health Plan?
Assign Commissions*
Will you be assigning your commissions to your upline agency?
Name*
Name as it appears on your insurance license
Address*
Agent or Principal Resident Address
Cell Phone
Other Phone
Birth Date
MM slash DD slash YYYY
Social Security Number
Agent NPN
State Requested
Which state(s) would you like contracting for?
Upload the Direct Deposit Agreement Form here
Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.