EASE | Heartland Partner

*Warning - Please be sure to complete the below form to its entirety. If you have any issues or questions about the form and/or submission, please contact [email protected].
Are you an EASE Broker or a Business Owner/HR Admin?*
EASE Broker, great! Please complete the Broker Application below:
Broker DBA Name*
Broker's Business Address*
Street Address City State ZIP Code
Broker's Website
Signer's Name*
First Last
Signer's Title*
Signer's Email*
Signer's Phone*
Are you an EASE user?*
Brokerage Type/Professional Services Type (Select All That Apply)*
- Property & Casualty
- Health & Benefits
- CPA
- Financial Advisor
- Benefits Administrator
Business Owner/HR Admin leveraging EASE services! Please complete the Employer Application below:
DBA Name*
Business Address*
Street Address City State ZIP Code
Are you an EASE user?*
Do you work with any Broker at the moment?*
If you answered yes, who is your Broker?*
Signer's Name*
First Last
Signer's Title*
Signer's Email*
Signer's Phone*
Please e-mail [email protected] if you have any issues with the above submission form.