Request to Contract | Western Asset Protection

First and Last Name (Legal Name)*
Phone Type
Email*
Phone
Street Address Address Line 2 City State ZIP Code
National Producer Number

Copy and paste this URL into your browser to look up your NPN number: http://www.nipr.com/PacNpnSearch.htm
Please set me up as:
- Business (EIN)
- Individual (SSN)
SSN
EIN
Agent's Business or DBA Name

Amerigroup
Current Certification Status with Amerigroup
Current Contracting Status with Amerigroup
I would like to contract for Amerigroup in these states
- Arizona
Additional States for Amerigroup
- Additional States
Currently WAP does not support these states on their website for Amerigroup
- Nevada
- Texas
- Washington

Banner University Health Plans
Current Certification Status with Banner University Health Plans
Current Contracting Status with Banner University Health Plans
I would like to contract for Banner University Health Plans in these states
- Arizona

Blue Cross Blue Shield MAPD AZ
Current Certification Status with Blue Cross Blue Shield MAPD AZ
Current Contracting Status with Blue Cross Blue Shield MAPD AZ
I would like to contract for Blue Cross Blue Shield MAPD AZ in these states
- Arizona

Blue Cross Blue Shield Med Supp
Current Certification Status with Blue Cross Blue Shield Med Supp
Current Contracting Status with Blue Cross Blue Shield Med Supp
I would like to contract for Blue Cross Blue Shield Med Supp in these states
- Arizona

Blue Cross Blue Shield National
Current Certification Status with Blue Cross Blue Shield National
Current Contracting Status with Blue Cross Blue Shield National
I would like to contract for Blue Cross Blue Shield National in these states
- Illinois
- New Mexico
- Texas
Additional States for Blue Cross Blue Shield National
- Additional States
Currently WAP does not support these states on their website for Blue Cross Blue Shield National
- Montana
- Oklahoma

Bright Health
Current Certification Status with Bright Health
Current Contracting Status with Bright Health
Hidden
I would like to contract with Bright Health in this State(s)
- Arizona
Additional States for Bright Health
- Additional States
Currently WAP does not support these states on their website for Bright Health
- Colorado

Bright Health IFP
Current Certification Status with Bright Health IFP
Current Contracting Status with Bright Health IFP
I would like to contract for Bright Health IFP in these State(s)
- Arizona
Additional States for Bright Health IFP
- Additional States
Currently WAP does not support these states on their website for Bright Health IFP
- Colorado

Steward Health Choice
Current Certification Status with Steward Health Choice
Current Contracting Status with Steward Health Choice
I would like to contract for Steward Health Choice in these states
- Arizona
- Utah

Arizona State License Number*

Copy and paste this URL into your browser to look up your license number: https://az.gov/app/doilookup/ProfessionalSearch
Colorado State License Number*
Hawaii State License Number*
Illinois State License Number*
Iowa State License Number*
Minnesota State License Number*
Nevada State License Number*
New Mexico State License Number*
Texas State License Number*
Washington State License Number*
Please upload your Insurance License (for each state listed above) or Check "On File" below
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