Medicare/Medicaid Provider Surety Bond Application

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Step 1
General Information

General Information

Let's start with the basics. Submit the requested information to the best of your knowledge.

Point of Contact Information

This will be used in all correspondence regarding your bond.

First Name
Last Name
Business Phone Ext:
Cell Phone
Verify Email

General Business Information

Please select the type of bond you need:
  • Alabama Medicaid
  • Florida Medicaid
  • Maine Medicaid
  • Medicare
  • Minnesota Medicaid - DME
  • Minnesota Medicaid - PCA
  • Texas Medicaid DME
  • Texas Medicaid EMS
  • Texas Medicaid HHA
  • Other
What is the effective date of this bond?
Were you referred by an agent?
Are you a current VGM Insurance Liability Customer?
Are you an AAHomecare Customer?
Please enter your American Association for Homecare Number:
Do you belong to a VGM Group? Tell me more about this.
Please enter your member number (separated by commas if multiple):
Are there any pending lawsuits, unsatisfied judgements or liens?
Please explain:
Have you been informed by Medicare or its subsidiaries that you need to obtain a bond for greater than $50,000? Tell me more about this.
Please explain:
Do you have any other surety bonds in force with any other surety company?
Have you or your company ever had a negative action regarding a surety bond?
Please explain:
Have you continuously been in business under the current name and ownership for at least three years?
What is your main line of business?
If other, please specify: