Submit an Application

Ready to submit an Application?

Email us your application here! If you do not have secure email, please fax your application to 918-878-5978. Please include the application (5 pages), a Scope of Appointment and any comments/questions you may have. We will be reaching out shortly with a confirmation email.

• Scope of Appointment
• Sign-in to your Broker Portal to submit an online application

To complete an enrollment by phone, you and your client can three-way call into our enrollment team at (918) 594-5275. One of our representatives will help you and your client complete their enrollment into our plan quickly over the phone. Scope of Appointment form (SOA) must then be sent in by broker.