Affiliate Signup

Thank you for your interest in becoming an affiliate with Travel MedEvac. Before you start the process please have your Tax ID Number on hand.

Upon our review of this application, you will be emailed the producer or advertiser agreement from Docusign which you can sign electronically. As soon as you sign the documents, you can log-in immediately to begin issuing policies (if you are a licensed agent) or referring customers to TME under an affiliate advertiser agreement (if you are not a licensed agent).

Agency / Business Owner's Name:*

Agency / Business Name:*

Select the option that applies to you*

Producer - Agent License Number*

Are you a U.S. taxpayer or file taxes in the U.S.?*

Address:*

Address Line 2:

City:*

Country:*

State:*

Zip Code:*

Phone Number*

E-Mail Address*

Tax Classification:*

Do you use a Social Security Number or Tax/ID?*

Tax ID/EIN:*

Social Security Number:*