Agent agreement

Complete and submit this form.

›
Agent
›
Get Appointed
›
Old Agent Agreement Form

Page last updated on: 2/22/25

*For J.D. Power 2024 award information, visit jdpower.com/awards

Privacy policy
Notice of Privacy Practices (NPP)
Terms of use
Developers
Non-discrimination notice
Sitemap

Language assistance available

Shqip
العربية
Assyrian
বাংলা
繁體中文
Deutsch
Italiano
日本語
한국어
Polski
Русский
Srpsko-hrvatski
Español
Tagalog
TiếngViệt

Enrollees may receive a copy of their Form 1095-B upon request by calling the customer service number on the back of their Member ID card, by logging into their Priority Health member account or by mailing in a request to Priority Health,1231 East Beltline Ave. NE, Grand Rapids, MI 49525-4501.