First Name: *

Middle Name:

Last Name: *

Date of Birth: * ex. MM-DD-YYYY

SSN: * ex. XXX-XX-XXXX

Company or DBA:

Tax ID or EIN: ex. XX-XXXXXXX

Email: *

Confirm Email: *

Password

Cannot contain your first or last name.
Must be at least 8 characters in length.
Must contain a number, special character, upper case letter, and lower case letter.

Password: *

Confirm Password: *

Cell Phone: * ex. XXX-XXX-XXXX

Alt Phone: ex. XXX-XXX-XXXX

Physical

Address: *

City: *

State: *

Zip: *

Same as Physical

Mailing

Address: *

City: *

State: *

Zip: *

Upline 1 Number: *

Upline 1 Percent: *

Upline 2 Number:

Upline 2 Percent:

Are you a US citizen? *

Yes No

Are you authorized to work in the United States? *

Yes No

Upload Proof (VISA..ect) *

Are you insurance licensed? *

Yes No

Resident License State:

Resident License Number:

License Date Acquired: (MM-DD-YYYY)

License Expiration Date: (MM-DD-YYYY)

Do you have E&O license?

Yes No

E&O Insurance Policy Number

Date Acquired: (MM-DD-YYYY)

Expiration Date: (MM-DD-YYYY)

Upload Proof *

Do you have a health insurance license?

Yes No

Health Insurance License State:

Health Insurance License Number:

Date Acquired: (MM-DD-YYYY)

Expiration Date: (MM-DD-YYYY)

Upload Proof *

Are you securities licensed? *

Yes No

What type of license?

Upload Proof *

Click here to download and review document.

I agree

Please check 'I agree' at the bottom of each disclosure after reviewing.

Signature *

ACH Deposit Information

Account Name: *

Account Type: *

Account Number: *

Routing Number: *

W-9 Information

Click here to download and review document.

1 Name (as shown on your income tax return)

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:

Individual/sole proprietor or single-member LLC

C Corporation

S Corporation

Partnership

Trust/estate

Limited Liability company. Enter the tax classification (C=C Corporation, S=S Corporation, P=Partnership)

Other (see instructions)

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting code (if any)

5 Address (number, street, and apt. or suite no.)

6 City, state, and ZIP code

7 List account number(s) here (optional)

Congratulations!

Welcome to WellthCare! You are now connected to multiple opportunities to help your client base. You will receive a welcome email shortly with further instructions.