Applicant Information

Please only enter a single email address.

Agency Information

Please only enter a single email address.

Assignment of Commission
Assignee Information
Bank Information (Direct Deposit)
Additional Information

Select the states in which you would like to be appointed. Please provide your license numbers for each respective state.

NOTE: If you are licensed and wish to sell in PA, you must be appointed prior to solicitation.

NOTE: Errors & Omissions Insurance is required to complete your application. If you are unable to upload the summary page of your E&O there are a couple options: This can either be sent by email to Carrissa@DirectBenefits.com or by fax to (651) 649-3502.

Questionaire

Has Authorized Representative /Agency / Agent ever: