Geisinger Health Plans Please complete the form and click Submit to request contracting. This field is hidden when viewing the formEmail* This field is hidden when viewing the formCarrierCarrierThis field is hidden when viewing the formUpline GAUpline GAThis field is hidden when viewing the formUpline MGAUpline MGAThis field is hidden when viewing the formUpline FMOUpline FMOCurrently contracted?*Are you currently contracted with Geisinger Health Plans? Yes No Agent or Agency?*Will you be applying as an Agent or as an Agency? Agent Agency Agency Name*Agency NameBusiness Tax ID*Business Tax IDAssign Commissions*Will your commissions be paid direct to you or to your upline agency? Direst Upline Agency Name the upline agency your commissions will be paid to.*Name the upline agency your commissions will be paid to.Upline Agency NPN*Upline Agency NPNName*First / Last Name First Last Address*Agent or Principal Resident Address Street City State ZIP Cell Phone*Cell PhoneOther PhoneOther PhoneBirth Date*Birth Date MM slash DD slash YYYY Social Security*Social Security NumberAgent NPN*Agent NPN
