Zion HealthShare Affiliate Contracting Request Join the premier medical cost sharing community. Affiliate InformationBusiness Name* Tax ID* Contact* First Last Phone*Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is your website? What geographic Region do you cover? Are you a Licensed Insurance Agent or DPC?How many contractors or affiliates are in your organization?How many years have you been designing/selling healthcare solutions?How much experience do you have with healthshares or costsharing programs?Does your company focus more on individuals or employer groups? Do you currently have members that you plan to move over to Zion HealthShare? Yes No How many members are you planning to move over to Zion HealthShare?HiddenZion Affiliate HiddenZion Affiliate - Not compensated HiddenZion HealthShare Independent Affiliate Agreement* See full agreement. Yes, I accept the terms of the Zion Health Independent Affiliate Agreement. HiddenZion HealthShare Independent Affiliate Agreement* See full agreement. Yes, I accept the terms of the Zion Health Independent Affiliate Agreement. HiddenSignature*HiddenDirect DepositAffiliate compensation is paid by direct deposit. Please provide the account information that you would like to receive your deposits to.HiddenAccount Name HiddenBank HiddenRouting Number* HiddenAccount Number* HiddenAgreement*Direct deposit of your compensation including bonuses, commissions and fees will be paid to the account indicated until you change the account in writing. I agree to allow Zion Health to deposit compensation into the account indicated. HiddenName* First Last HiddenSignature* Δ
