SCAN

Please complete the form and click Submit to request contracting.

REQUIRED DOCUMENTS: W-9 (MUST be dated within 30 days of submission; IF FILLING OUT AS AN AGENCY, EIN and SSN are required),  Direct Deposit Form (with voided check), WAP Assignment of Commissions, Life & Health Insurance License, E & O Certificate, and AHIP Certificate; the SCAN Agency Intake Form is also required if requesting as an agency. Please upload them as a PDF.