Broker Registration

Agent Registration

Enter your contact information below to submit your broker registration to PreferredOne.

Enter your contact information below to submit your agent registration to Aspirus Health Plan.

First Name:

Last Name:

Phone Number:

Address:

City:

State:

Zip:

Email Address: Invalid Email

Agency Website

Broker Type: Agent Type:

Receive e-newsletter and announcements:

Yes

Please provide the following information, this will help us serve you better when we contact you:

How many individual members do you currently have on the books?

Name of your Agency:

How long have you been selling in the market you are inquiring about?

List the companies you are currently appointed with and percentage of book with each carrier:

What products do you currently Market? (Medical, Dental, Medicare, P & C, etc.)

How many groups do you currently have on the books?

How many groups do you have in each of the following:

1 ee

2-4 ees

5-9 ees

10-25 ees

26-50 ees

50+ ees

Why are you interested in selling for Aspirus Health Plan?

Have you had a bankruptcy within the last five years?

Yes