We are partnering with eHealthApp to collect your
enrollment information efficiently and more securely.

Complete the form below to create your personalized
login. After submitting the request, you will receive an
email with your username and password. Please follow
the instructions on the home page after logging in.

First Name:

Last Name:

Email:



We are partnering with eHealthApp to bring our clients powerful benefit enrollment solutions.

Here are some of the features you will enjoy with your new portal:

  • Single Application for Quoting & Enrollment to Multiple Carriers
  • Group Document Storage & Delivery
  • Multi-Lingual Support with Google Translate™
  • Increased Participation in Ancillary/Voluntary Products
  • Personal Service on a Safe, Secure & Trusted Platform

    Please complete the form below to get started:

    Company Name:*

    Group Identifier:*

    First Name:*

    Last Name:*

    Email:*

    Phone:

    Company Web Site:

    Benefits Renewal Date:


    Fields marked with * are required


    For questions, please contact:
    Broker Name
    (999) 999-9999
    BrokerEmail@BrokerDomain.com