GO ENROLL 123

Rep Registration

Broker information

General Agent ID *

Personal Information

First Name *

Middle Initial

Last Name *

SSN *

Date of Birth *

Next Save & Continue Later

Login Information

Email *

Password *

Minimum 8 characters, at least one letter, one number & one special character

Re-Type Password *

Next Save & Continue Later

Contact Information

Mobile Phone Number *

Select Time Zone *

Mobile number 2

Phone No

Fax

Next Save & Continue Later

Address Information

Street Address1 *

Apt/Suite/Other

City *

State *

Zip Code *

Continue without Address Validation

Next Save & Continue Later

Registration Type

Registration Type *

Next Save & Continue Later

Business Information

Business Tax ID *

Business Name *

Business Street Address *

Apt/Suite/Other

Business City *

Business State *

Business Zip Code *

Continue without Address Validation

Next Save & Continue Later

Payment Information

Pay to: *

Individual

Business

How do you want to be paid? *

Check

ACH

If ACH, please complete the following: *

Routing Number

What is Routing Number ?

Bank Name

Account Number

Name on Bank Account

Account Type

Account Holder Type

Next Save & Continue Later

Signature & Verification

Type your full name which will be your “signature” to verify application terms and agreement: *

Signature Date:

Verification Code *

D7BIQ

Verify Code *

Access to the insurance plans and large group pricing on this website is predicated upon joining Elevate Wellness, a national association with over 100,000 members.
Click here to Learn more

Rep Registration

Broker information

Personal Information

Login Information

Contact Information

Address Information

Registration Type

Business Information

Payment Information

Signature & Verification

Access to the insurance plans and large group pricing on this website is predicated upon joining Elevate Wellness, a national association with over 100,000 members. Click here to Learn more

Questions? Call 888-243-4011 We're standing by to help you make the best decision.

Access to the insurance plans and large group pricing on this website is predicated upon joining Elevate Wellness, a national association with over 100,000 members.
Click here to Learn more