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 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 Health?YesNoHow many members are you planning to move over to Zion Health?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*
