DIRECT PAY CONTRACTING SUBMISSION FORM

Please fill in all of the required information below. This form will automatically populate into PDFs for:

Fidelis Information Form
W-9 form
Direct Deposit Authorization Form

You can attach all relevant documents by clicking the “Choose Files” button at the bottom of the page, including any additional pieces discussed with Contracting.

If you have any questions or need assistance, please contact the Contracting Department at contracting@fidelisins.com or call 480.877.4948

Agent Name:

Immediate Upline:

SSN:

Tax ID:

Agency Name:

Click this box if you will have Agents under your Agency

Direct Pay

LOA(Licensed Only Agent)

Address:

Unit:

City:

State:

Zip:

Business Address:

Unit:

City:

State:

Zip:

Business Phone:

Cell Phone:

Email Address:

Date of Birth:

Agent NPN:

Agency/Entity NPN:

Marital Status:

Name of Bank:

Account Number:

9 Digit Routing Number:

Required Documents:

AHIP
E & O
License
Voided Check

Attachments

Clicking “Submit” will open a screen with three forms. These forms will add the information you provided in the form above.

Please carefully review that information and fill out the remaining fields, including your signature.

Once you click “I agree,” the documents you’ve uploaded and the signed forms will be sent to our Contracting Team.

DIRECT PAY CONTRACTING SUBMISSION FORM

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