Zion Health Affiliate Contracting Request Join the premier medical cost sharing community. 1 Affiliate Type2 Affiliate Information What best describes your affiliate relationship?*Insurance Agent/BrokerDirect Primary Care Practice (compensated)Direct Primary Care Practice (not compensated)Other Affiliate InformationBusiness Name*Tax ID*Contact* First Last Phone*Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Zion AffiliateZion Affiliate - Not compensatedZion Health Independent Affiliate Agreement* See full agreement. Yes, I accept the terms of the Zion Health Independent Affiliate Agreement. Zion Health Independent Affiliate Agreement* See full agreement. Yes, I accept the terms of the Zion Health Independent Affiliate Agreement. Signature*Direct DepositAffiliate compensation is paid by direct deposit. Please provide the account information that you would like to receive your deposits to.Account NameBankRouting Number*Account Number*Agreement*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. Name* First Last Signature*
