Anthem-Appointed Broker Sign Up - Vegas Chamber

For Anthem-appointed brokers who are not currently Vegas Chamber members, and are interested in selling the Chamber Health Plan, please complete the form below for membership information.

Your Name (required)

Your Email (required)

Referred By (if applicable)

Company Name

Physical Address

City

State

Zip

Are you currently open for business at this address?
YesNo

Mailing address

City

State

Zip

Phone

Ext.

Primary Contact (Please enter Last Name, First Name)

Title

Email (Primary Contact)

Additional email addresses you would like to have added to our contact list:

Website (add http:// in front of address)

Is your website currently "live"?
YesNo

Proud Member Partners