Broker Application
Your Full Name
Date of Birth
Name of your company
EIN or SS#
Your Mailing Address:
City/state/zip
 Email:
Are you a licensed health insurance agent?
If yes, State lic #
yes
no
Phone Number
 Mobile Phone Number
Website URL
Fax Number
Please List all products you currently offer for
employer sponsored health care
Please list all general types of products you represent
Please provide a brief description of your company or business background.
If submitting a resume, please cut and paste it here.
Disclaimer
Equity Health Plan™, Equity Health, LLC and the Health Security Organization are not affiliated with any insurance companies and do not offer
insurance products. An Equity Health Plan may or may not be sold by a licensed insurance agent and it may be used to purchase insurance products.
The Equity Health Plan may also be purchased as a complimentary product to an insurance plan. If an insurance product is coupled with an Equity
Health Plan it does not establish an agreement or imply an established relationship between Equity Health, LLC and the insurance company.
The Equity Health Plan cannot guarantee that desired health care services will be available to a member on acceptable terms to the member. Equity
Health Plan also cannot guarantee pricing, scheduling, or any standard of quality related to the services provided by third party entities, such as
providers, to the members.
I authorize EquityHealth LLC to investigate this application, including contacting former employers and
performing a background check. I understand this information will be used solely for the purpose of evaluating
a possible future relationship with EquityHealth LLC. This document in no way represents an agreement for
employment, authorization to represent Equity Health LLC Products or Services, or any type of contract for
any reason. By clicking the agreement box, you are agreeing to the terms of this application
I agree to the terms of this application
Broker Home
Contact Us
Please complete this application as completely as possible. We will forward an email to you with a link to our
broker services page. There you can look over the materials we provide, learn more about the products and get
ready to offer the EquityHealth Program to you clients. Where you do not have any information to provide, do not
leave the field blank, please type in "No Information Provided". Thank You for applying to EquityHealth.