IMA Health Plan

Broker Registration Request

The IMA Health Plan can be quoted and sold through any properly licensed and appointed insurance agent in the State of Illinois. Interested insurance brokers should complete the following questionnaire to request a registration for the IMA Health Plan. Once submitted and reviewed, the individual completing this request will be contacted by the IMA with instructions for finalizing the registration process and obtaining quotes.

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your title?

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* 4. What is your email address?

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* 5. What is your best contact phone number?

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* 6. Are you completing this appointment request as an individual or corporate entity?

Individual

Corporate Entity

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* 7. What is the name of the individual or corporate entity requesting the appointment?

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* 8. If this appointment request is for a corporate entity, will multiple licensed insurance producers within your organization be seeking an appointment for the IMA Health Plan?

Yes

Not Applicable - I am requesting an individual appointment.